CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: * Pt intubated and with no accompanying family so below
information obtained from ED report and OMR review*
86 yr/o F with Hx of metastatic breast CA (lungs, skull bones),
DVT (on Fragmin via study protocol), HTN (on nifedipine) who
presented to clinic today for an appointment feeling acutely
SOB.
.
O2 sat found to be 60% on RA when EMS arrived. She was placed on
a NRB and found to be 77% with this on arrival to [**Hospital1 18**] ED.
Initial vitals showed HR 138 and SBP > 200. Pt found to have
bilateral rales, perioral cyanosis, 2+ pittle LE edema, and very
poor mental status unable to answer questions or discuss code
status. EKG was reported to have peaked T waves V1-V4 as well as
? j point elevationand LBBB (known LBBB in past).  Cards fellow
thought T waves rate related and did bedside ECHO with normal EF
but hypokinesis in LAD distribution. Pt was given 40mg IV lasix,
750mg IV levofloxacin, and Nitro paste, and transiently put on
BiPAP but was believed to be fatiguing within 5 min so was
intubated with propofol in the ED. SBP fell to 80s with propofol
and intubation so pt received a 600cc bolus. ETT pulled back
from 25 to 23 in ED.
.
At time of transfer to CCU pt had put out 150cc urine and had
vitals showing HR 77, BP 125/73, O2 Sat 100% on CMV TV 500, RR
20, PEEP 5, FiO2 100%. Gas showed 7.32 / 52 / 100 / 28 with
PaO2/FiO2 100 but question that this gas was drawn at same time
as being intubated and without full effect of vent as repeat gas
on vent settings CMV TV 500, PEEP 5, RR 14, FiO2 100% showed
7.42 / 44 / 392 / 30.
.
LE swelling first noted by PCP [**Last Name (NamePattern4) **] [**1-25**] both by pt report that
Heme/Onc doctor told her she needed lasix and by exam in PCP
[**Name Initial (PRE) 3726**]. Started on 20mg PO lasix in Feburary. Heme/Onc note
reports leg swelling last year found to be DVT in [**2142-2-12**] and
has been on Dalteparin via [**Company 2860**] protocol since. This new
swelling is apparently different than past DVT swelling and had
raised question of cardiac congestive cause in ambulatory
setting.
.
Per brief discussion with HCP [**Name (NI) 4457**], pt is an avid musician and
plays the trumpet. Roughly 1 week ago patient started
complaining of trouble holding her air playing the trumpet which
had never been a problem before.

MEDICAL HISTORY: per OMR review
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])

MEDICATION ON ADMISSION: - Dalteparin (Fragmin) (dosed at [**Company 2860**] as part of study protocol)
- Fluoxymesterone [Androxy] 10mg [**Hospital1 **]
- Furosemide 20mg daily ([**2143-2-1**])
- Nifedipine ER 60mg daily
- Omperazole 20mg daily
- Oxycodone-Acetaminophen 5mg-325mg QID PRN
- ASA 325mg daily

ALLERGIES: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

PHYSICAL EXAM: Admission:
VS: T=afebrile BP=153/75 HR=76 RR=16 O2 sat=100% on 60% FiO2
GENERAL: Intubated and sedated. Opens eyes to command.
HEENT: NCAT. Sclera anicteric. PERRL, no pallor or cyanosis of
the oral mucosa.
NECK: Supple with mild JVP elevation roughly 10mmHg
CARDIAC: normal S1, S2. ? murmurs/extra heart sounds but
difficult to ascertain underneath ventilator sounds. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Crackles at lateral bases, course breath sounds anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds
EXTREMITIES: 1+ LE edema, some redness in pre-tibial areas
bilaterally. Extremities warm and well perfused.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **].
Father died at 49 from coronary thrombosis.
Sister with [**Name2 (NI) 499**] cancer.
Another sister with pancreatic cancer.
Niece and nephew (in same family) both with [**Name (NI) 4278**].
She is last surviving relative.

SOCIAL HISTORY: She lives alone in [**Location (un) 96700**] and is very active at
baseline.  Ambulates independently.  Spends Mon/Fri at the
cultural center, Tues playing trumpet in a band, and Weds/Thurs
running erands.  Has 3 cars at home and drives.  Retired
teacher.  Never married and without children.  Smoked 2ppd x
10-15 years until [**2094**], glass of wine <1x/week.  No other drug
use.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None
Acute on chronic diastolic heart failure,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Unspecified essential hypertension,Pain in joint, shoulder region,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Knee joint replacement,Family history of malignant neoplasm of gastrointestinal tract
Ac on chr diast hrt fail,Secondary malig neo lung,Secondary malig neo bone,Hypertension NOS,Joint pain-shlder,Hx of breast malignancy,Hx of colonic malignancy,Joint replaced knee,Family hx-gi malignancy
Admission Date:  [**2143-3-6**]              Discharge Date:   [**2143-3-9**]


Service: MEDICINE

Allergies:
Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Endotracheal intubation and mechanical ventilation
Arterial Line placement


History of Present Illness:
* Pt intubated and with no accompanying family so below
information obtained from ED report and OMR review*
86 yr/o F with Hx of metastatic breast CA (lungs, skull bones),
DVT (on Fragmin via study protocol), HTN (on nifedipine) who
presented to clinic today for an appointment feeling acutely
SOB.
.
O2 sat found to be 60% on RA when EMS arrived. She was placed on
a NRB and found to be 77% with this on arrival to [**Hospital1 18**] ED.
Initial vitals showed HR 138 and SBP > 200. Pt found to have
bilateral rales, perioral cyanosis, 2+ pittle LE edema, and very
poor mental status unable to answer questions or discuss code
status. EKG was reported to have peaked T waves V1-V4 as well as
? j point elevationand LBBB (known LBBB in past).  Cards fellow
thought T waves rate related and did bedside ECHO with normal EF
but hypokinesis in LAD distribution. Pt was given 40mg IV lasix,
750mg IV levofloxacin, and Nitro paste, and transiently put on
BiPAP but was believed to be fatiguing within 5 min so was
intubated with propofol in the ED. SBP fell to 80s with propofol
and intubation so pt received a 600cc bolus. ETT pulled back
from 25 to 23 in ED.
.
At time of transfer to CCU pt had put out 150cc urine and had
vitals showing HR 77, BP 125/73, O2 Sat 100% on CMV TV 500, RR
20, PEEP 5, FiO2 100%. Gas showed 7.32 / 52 / 100 / 28 with
PaO2/FiO2 100 but question that this gas was drawn at same time
as being intubated and without full effect of vent as repeat gas
on vent settings CMV TV 500, PEEP 5, RR 14, FiO2 100% showed
7.42 / 44 / 392 / 30.
.
LE swelling first noted by PCP [**Last Name (NamePattern4) **] [**1-25**] both by pt report that
Heme/Onc doctor told her she needed lasix and by exam in PCP
[**Name Initial (PRE) 3726**]. Started on 20mg PO lasix in Feburary. Heme/Onc note
reports leg swelling last year found to be DVT in [**2142-2-12**] and
has been on Dalteparin via [**Company 2860**] protocol since. This new
swelling is apparently different than past DVT swelling and had
raised question of cardiac congestive cause in ambulatory
setting.
.
Per brief discussion with HCP [**Name (NI) 4457**], pt is an avid musician and
plays the trumpet. Roughly 1 week ago patient started
complaining of trouble holding her air playing the trumpet which
had never been a problem before.

Past Medical History:
per OMR review
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])

PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]

Social History:
She lives alone in [**Location (un) 96700**] and is very active at
baseline.  Ambulates independently.  Spends Mon/Fri at the
cultural center, Tues playing trumpet in a band, and Weds/Thurs
running erands.  Has 3 cars at home and drives.  Retired
teacher.  Never married and without children.  Smoked 2ppd x
10-15 years until [**2094**], glass of wine <1x/week.  No other drug
use.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None

Family History:
Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **].
Father died at 49 from coronary thrombosis.
Sister with [**Name2 (NI) 499**] cancer.
Another sister with pancreatic cancer.
Niece and nephew (in same family) both with [**Name (NI) 4278**].
She is last surviving relative.


Physical Exam:
Admission:
VS: T=afebrile BP=153/75 HR=76 RR=16 O2 sat=100% on 60% FiO2
GENERAL: Intubated and sedated. Opens eyes to command.
HEENT: NCAT. Sclera anicteric. PERRL, no pallor or cyanosis of
the oral mucosa.
NECK: Supple with mild JVP elevation roughly 10mmHg
CARDIAC: normal S1, S2. ? murmurs/extra heart sounds but
difficult to ascertain underneath ventilator sounds. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Crackles at lateral bases, course breath sounds anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds
EXTREMITIES: 1+ LE edema, some redness in pre-tibial areas
bilaterally. Extremities warm and well perfused.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

Discharge Exam:
Gen: alert, oriented, energetic, talkative
HEENT: supple, JVD at 12 cm
CV: RRR, no M/R/G
RESP:crackles bibasilar
ABD: soft, NT, ND
EXTR: 2+ pitting peripheral edema
NEURO: A/O
Extremeties: warm
Pulses:
Right: DP 1+ PT 1+
Left: DP 2+ PT 1+
Skin: intact


Pertinent Results:
Admission Labs:
[**2143-3-6**] 11:18AM BLOOD WBC-10.7 RBC-5.20 Hgb-14.2 Hct-44.9
MCV-86 MCH-27.2 MCHC-31.6 RDW-16.0* Plt Ct-543*
[**2143-3-6**] 11:18AM BLOOD Neuts-76.1* Lymphs-16.9* Monos-5.6
Eos-0.6 Baso-0.7
[**2143-3-7**] 03:32AM BLOOD PT-13.2 PTT-21.2* INR(PT)-1.1
[**2143-3-6**] 09:48PM BLOOD Glucose-113* UreaN-25* Creat-1.0 Na-139
K-3.5 Cl-97 HCO3-31 AnGap-15
[**2143-3-6**] 11:18AM BLOOD Glucose-173* UreaN-24* Creat-1.1 Na-139
K-5.5* Cl-98 HCO3-30 AnGap-17
[**2143-3-7**] 03:32AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.0

Cardiac:
[**2143-3-7**] 03:32AM BLOOD CK-MB-4 cTropnT-0.06*
[**2143-3-6**] 09:48PM BLOOD CK-MB-7 cTropnT-0.06*
[**2143-3-6**] 11:18AM BLOOD cTropnT-0.02*
[**2143-3-6**] 11:18AM BLOOD CK-MB-6 proBNP-1216*

ABGs:
[**2143-3-6**] 10:06PM BLOOD Type-ART pO2-124* pCO2-37 pH-7.51*
calTCO2-31* Base XS-6
[**2143-3-6**] 02:28PM BLOOD Type-ART Tidal V-400 PEEP-5 FiO2-100
pO2-392* pCO2-44 pH-7.42 calTCO2-30 Base XS-4 AADO2-292 REQ
O2-54 -ASSIST/CON Intubat-INTUBATED
[**2143-3-6**] 12:17PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100
pO2-100 pCO2-52* pH-7.32* calTCO2-28 Base XS-0 AADO2-576 REQ
O2-93 -ASSIST/CON Intubat-INTUBATED
[**2143-3-6**] 10:06PM BLOOD Lactate-1.1

ECHO [**2143-3-6**]:
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
distal septum and apex. The remaining segments contract normally
(LVEF = 50-55 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. No aortic regurgitation is seen. Cannot exclude
aortic stenosis. The mitral valve leaflets are moderately
thickened. There is severe mitral annular calcification. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is a trivial/physiologic pericardial
effusion.

IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Mild mitral regurgitation.

CTA Chest [**2143-3-6**]:
1. No evidence of pulmonary embolism.
2. Severe pulmonary edema, scattered subsegmental atelectasis,
and moderate bilateral pleural effusions, right greater than
left. It should be noted that processes such as pulmonary
hemorrhage can have a similar appearance. Given substantial
parenchymal abnormality, supervening consolidation or focal
lesion cannot be excluded.

CXR [**2143-3-7**]:
IMPRESSION: Interval redistribution of bilateral opacities from
upper to
lower zones. Overall mild improvement of now mild-to-moderate
pulmonary
edema. Endotracheal tube now in standard position.

Discharge Exam:
[**2143-3-9**] 08:55AM BLOOD WBC-9.0 RBC-4.30 Hgb-11.6* Hct-36.7
MCV-85 MCH-26.9* MCHC-31.6 RDW-16.0* Plt Ct-348
[**2143-3-9**] 08:55AM BLOOD Glucose-106* UreaN-29* Creat-0.9 Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14

Brief Hospital Course:
Patient is an 86 yr old F with Hx of metastatic breast CA
(lungs, skull), DVT (completed course of Dalteparin (Fragmin)
via study protocol), HTN (on nifedipine) who presented to clinic
with acute SOB with CXR findings concerning for flash pulmonary
edema requring brief intubation with resolution of pulmonary
edema with diuresis.

# Pulmonary Edema: Patient had severe hypoxia at rest in clinic
and only mild improvement to high 70s with NRB. Initial ABG in
ED was likely falsely hypoxic as obtained at parallel time with
intubation and repeat gas 90min later with no sig change in vent
settings much improved an no longer with PaO2/FiO2 consistent
with ARDS. Presumed cause of hypoxia was flash pulm edema
although unclear what baseline lung function is with prior
documentation of lung mets. Patient received 1 dose of
levofloxacin in the ED. CT read confirms that lung findings most
likely due to severe pulmonary edema. She was intubated in the
ED and was extubated the next morning after she was net negative
2.5 L with diuresis with iv lasix. Pt given additional doses of
IV diuresis for further diuresis on [**3-7**] and [**3-8**] and then
discharged on 20mg of PO lasix to be uptitrated as needed as an
outpatient. At time of discharge pt was able to ambulate without
RA oxygenation falling to less than 92% on RA.

# CORONARIES: No history of coronary disease. Only has HTN
documented as RF although no recent lipid panels/A1C and last
A1C in [**2140**] was mildly elevated at 6.4. There is evidence of
coronary disease on chest CTA. Bedside ECHO in ER showed some
question of hypokinesis in LAD distribution consistent with CAD
but EKG without signs of active ischemia and biomarkers negative
x 2. Initially was started on a heparin gtt as thought that pt
still therapeutically anticoagulated as an outpatient. After pt
extubated the next day and able to report that no longer taking
therapeutic anticoagulation she was switched to sub-Q heparin.
No need for cardiac catheterization as did not appear that
presentation due to acute ischemic event.

# PUMP: Preserved LVEF ECHO with some mild regional dysfunction
with hypokinesis of distal septum and apex. CXR showed signs of
acute pulm edema likely related to hypertension.

# RHYTHM: Was initially in sinus tach in 130s but after initial
interventions in ER her HR decreased down into 70s.

# HTN: BPs in last few months have been documented in 130-140s
systolic with diastolics in 60-70s. Pt had significantly
elevated pressures on presentation with Sys BP >200 but came
down to 130s with lasix, nitro paste, and intubation/sedation.
She is only on nifedipine at home for BP control and was
recently placed on low-dose lasix for LE edema more than BP. In
the CCU her blood pressure was well controlled. Her nifedipine
was intitially held and the next day she was started on
lisinopril and carvedilol and nifedipine stopped. She was
discharged home on carvedilol uptitrated to 6.25mg [**Hospital1 **] and
lisinopril uptitrated to 10mg daily at time of discharge.

# Breast Ca: Patient has known mets to both skull bones and
lungs although documentation of lung mets not noted in our
imaging as no chest imaging present. She is on Tamoxifen and
Fluoxymesterone as outpt through [**Company 2860**] and seems to be fairly
stable per PCP [**Name Initial (PRE) 12883**]. Unclear if has home O2 reqirement with
lung mets. Head CT showed no evidence of intra-cranial bleed or
intra-cranial mets. Her outpatient Fluoxymesterone was
non-formulary and unavailable and was not given this
hospitalization.

# DVT Hx: Hx DVT last year in setting of known malignancy and
multiple past ortho proceedures. Was on Fragmin as outpt via
study protocol at [**Company 2860**] and has completed a 12 month course. She
was initially on heparin drip which was stopped when CTA showed
no evidence of PE. She was then maintained on heparin subQ for
DVT prophylaxis.

Medications on Admission:
- Dalteparin (Fragmin) (dosed at [**Company 2860**] as part of study protocol)
- Fluoxymesterone [Androxy] 10mg [**Hospital1 **]
- Furosemide 20mg daily ([**2143-2-1**])
- Nifedipine ER 60mg daily
- Omperazole 20mg daily
- Oxycodone-Acetaminophen 5mg-325mg QID PRN
- ASA 325mg daily

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. fluoxymesterone 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
8. Roxicet 5-325 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for pain.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Hypertension
Metastatic Breat Cancer
Osteoarthritis
Left Shoulder pain


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


Discharge Instructions:
Your blood pressure was very high and you developed acute
diastolic congestive heart failure with fluid in your lungs. You
will need to change your blood pressure medicines to prevent
this from happening again. We increased your blood pressure
medications to bring your blood pressure into a good range. We
gave you diuretics to get rid of the extra fluid and your dose
of this diuretic (lasix) may need to be increased by your
outpatient doctors if [**Name5 (PTitle) **] continue to retain extra fluid. Please
weigh yourself every morning, call Dr. [**Last Name (STitle) 2204**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the follwoing changes in your medicines:
1. Stop taking nifedipine
2. Decrease aspirin to 81 mg daily
3. Start taking Lisinopril 10mg by mouth at bedtime to lower
your blood pressure
4. Start taking Carvedilol 6.25mg twice a day to lower your
blood pressure and heart rate
5. Continue taking Lasix 20mg by mouth daily. This dose may need
to be increased to 40mg daily if your doctors [**Name5 (PTitle) **] that [**Name5 (PTitle) **]
are still retaining fluid.
6. Continue taking your other home medications

Followup Instructions:
If you continue to retain extra fluid, you may need to have your
dose of lasix increased by one of your outpatient doctors.

Department: Cardiology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
When: You will be called by the office regarding your
appointment for 1-2 weeks after your discharge. If you have not
heard from the office in 2 business days, please call the number
listed below.
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]

Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]
When: Wednesday [**2143-3-13**] at 10 AM
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 2205**]
{'Acute on chronic diastolic heart failure,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Unspecified essential hypertension,Pain in joint, shoulder region,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Knee joint replacement,Family history of malignant neoplasm of gastrointestinal tract'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: * Pt intubated and with no accompanying family so below
information obtained from ED report and OMR review*
86 yr/o F with Hx of metastatic breast CA (lungs, skull bones),
DVT (on Fragmin via study protocol), HTN (on nifedipine) who
presented to clinic today for an appointment feeling acutely
SOB.
.
O2 sat found to be 60% on RA when EMS arrived. She was placed on
a NRB and found to be 77% with this on arrival to [**Hospital1 18**] ED.
Initial vitals showed HR 138 and SBP > 200. Pt found to have
bilateral rales, perioral cyanosis, 2+ pittle LE edema, and very
poor mental status unable to answer questions or discuss code
status. EKG was reported to have peaked T waves V1-V4 as well as
? j point elevationand LBBB (known LBBB in past).  Cards fellow
thought T waves rate related and did bedside ECHO with normal EF
but hypokinesis in LAD distribution. Pt was given 40mg IV lasix,
750mg IV levofloxacin, and Nitro paste, and transiently put on
BiPAP but was believed to be fatiguing within 5 min so was
intubated with propofol in the ED. SBP fell to 80s with propofol
and intubation so pt received a 600cc bolus. ETT pulled back
from 25 to 23 in ED.
.
At time of transfer to CCU pt had put out 150cc urine and had
vitals showing HR 77, BP 125/73, O2 Sat 100% on CMV TV 500, RR
20, PEEP 5, FiO2 100%. Gas showed 7.32 / 52 / 100 / 28 with
PaO2/FiO2 100 but question that this gas was drawn at same time
as being intubated and without full effect of vent as repeat gas
on vent settings CMV TV 500, PEEP 5, RR 14, FiO2 100% showed
7.42 / 44 / 392 / 30.
.
LE swelling first noted by PCP [**Last Name (NamePattern4) **] [**1-25**] both by pt report that
Heme/Onc doctor told her she needed lasix and by exam in PCP
[**Name Initial (PRE) 3726**]. Started on 20mg PO lasix in Feburary. Heme/Onc note
reports leg swelling last year found to be DVT in [**2142-2-12**] and
has been on Dalteparin via [**Company 2860**] protocol since. This new
swelling is apparently different than past DVT swelling and had
raised question of cardiac congestive cause in ambulatory
setting.
.
Per brief discussion with HCP [**Name (NI) 4457**], pt is an avid musician and
plays the trumpet. Roughly 1 week ago patient started
complaining of trouble holding her air playing the trumpet which
had never been a problem before.

MEDICAL HISTORY: per OMR review
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])

MEDICATION ON ADMISSION: - Dalteparin (Fragmin) (dosed at [**Company 2860**] as part of study protocol)
- Fluoxymesterone [Androxy] 10mg [**Hospital1 **]
- Furosemide 20mg daily ([**2143-2-1**])
- Nifedipine ER 60mg daily
- Omperazole 20mg daily
- Oxycodone-Acetaminophen 5mg-325mg QID PRN
- ASA 325mg daily

ALLERGIES: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

PHYSICAL EXAM: Admission:
VS: T=afebrile BP=153/75 HR=76 RR=16 O2 sat=100% on 60% FiO2
GENERAL: Intubated and sedated. Opens eyes to command.
HEENT: NCAT. Sclera anicteric. PERRL, no pallor or cyanosis of
the oral mucosa.
NECK: Supple with mild JVP elevation roughly 10mmHg
CARDIAC: normal S1, S2. ? murmurs/extra heart sounds but
difficult to ascertain underneath ventilator sounds. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Crackles at lateral bases, course breath sounds anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Normoactive bowel
sounds
EXTREMITIES: 1+ LE edema, some redness in pre-tibial areas
bilaterally. Extremities warm and well perfused.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **].
Father died at 49 from coronary thrombosis.
Sister with [**Name2 (NI) 499**] cancer.
Another sister with pancreatic cancer.
Niece and nephew (in same family) both with [**Name (NI) 4278**].
She is last surviving relative.

SOCIAL HISTORY: She lives alone in [**Location (un) 96700**] and is very active at
baseline.  Ambulates independently.  Spends Mon/Fri at the
cultural center, Tues playing trumpet in a band, and Weds/Thurs
running erands.  Has 3 cars at home and drives.  Retired
teacher.  Never married and without children.  Smoked 2ppd x
10-15 years until [**2094**], glass of wine <1x/week.  No other drug
use.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None 

### Response:
{'Acute on chronic diastolic heart failure,Secondary malignant neoplasm of lung,Secondary malignant neoplasm of bone and bone marrow,Unspecified essential hypertension,Pain in joint, shoulder region,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Knee joint replacement,Family history of malignant neoplasm of gastrointestinal tract'}
