CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: HPI:  69-yo-woman w/ HIV, COPD, ESRD on HD presents w/ shortness
of breath x 2 hours.  She reportedly was feeling well until 7pm,
when she developed dyspnea at rest.  The dyspnea became
progressively worse over the next 2 hours, prompting
presentation to the ED.  The pt did not complain of any fever,
chills, increased cough, chest pain, abd pain, melena, or
hematochezia.  On arrival in the ED, her  temp 103, HR 162, BP
230/104, RR 38.  She was in acute resp distress and was
intubated immediately and placed on CMV ventilation.  Propofol
gtt was started for sedation, resulting in decreased BP to
70/42.  Propofol was then d/c, and levophed was added, resulting
in increased BP to 118/55.  Initial CXR was concerning for PNA
w/ diffuse interstitial infiltrates, and the pt was treated w/
levo/vanco/ flagyl/bactrim/hydrocortisone.  The MICU team was
then called for further evaluation.

MEDICAL HISTORY: Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

MEDICATION ON ADMISSION: Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q 4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
Coumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution [**Hospital1 **]: As decided at dialysis
  Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 q day
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 q day
Isordil 10 [**Hospital1 **]

ALLERGIES: Motrin / Lipitor

PHYSICAL EXAM: On admission to MICU:
PE:  T 103, HR 112, BP 118/55, O2 sat 100% CMV 500 x 12/40%/5
Gen: chronically ill appearing woman lying flat in bed,
intubated, moving all 4 extremities in NAD.
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Pulm: coarse BS throughout, no wheezes or crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B, no edema
Neuro: pt too lethargic to cooperate; moving all extremities
spontaneously and follows basic commands

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history)
Acute respiratory failure,Congestive heart failure, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Acidosis,Acute kidney failure, unspecified,Mitral valve disorders,End stage renal disease,Diseases of tricuspid valve,Chronic airway obstruction, not elsewhere classified,Anemia in chronic kidney disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Acute respiratry failure,CHF NOS,Mal neo upper lobe lung,Acidosis,Acute kidney failure NOS,Mitral valve disorder,End stage renal disease,Tricuspid valve disease,Chr airway obstruct NEC,Anemia in chr kidney dis,Asymp hiv infectn status,Crnry athrscl natve vssl,Long-term use anticoagul,Status-post ptca,Old myocardial infarct,DMII wo cmp nt st uncntr
Admission Date:  [**2115-11-28**]              Discharge Date:   [**2115-12-5**]

Date of Birth:  [**2046-6-27**]             Sex:   F

Service: MEDICINE

Allergies:
Motrin / Lipitor

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
Endotracheal intubation.
Chest CT
Hemodialyis with additional ultrafiltration sessions.

History of Present Illness:
HPI:  69-yo-woman w/ HIV, COPD, ESRD on HD presents w/ shortness
of breath x 2 hours.  She reportedly was feeling well until 7pm,
when she developed dyspnea at rest.  The dyspnea became
progressively worse over the next 2 hours, prompting
presentation to the ED.  The pt did not complain of any fever,
chills, increased cough, chest pain, abd pain, melena, or
hematochezia.  On arrival in the ED, her  temp 103, HR 162, BP
230/104, RR 38.  She was in acute resp distress and was
intubated immediately and placed on CMV ventilation.  Propofol
gtt was started for sedation, resulting in decreased BP to
70/42.  Propofol was then d/c, and levophed was added, resulting
in increased BP to 118/55.  Initial CXR was concerning for PNA
w/ diffuse interstitial infiltrates, and the pt was treated w/
levo/vanco/ flagyl/bactrim/hydrocortisone.  The MICU team was
then called for further evaluation.

Past Medical History:
Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

Social History:
Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history)


Family History:
Non-contributory

Physical Exam:
On admission to MICU:
PE:  T 103, HR 112, BP 118/55, O2 sat 100% CMV 500 x 12/40%/5
Gen: chronically ill appearing woman lying flat in bed,
intubated, moving all 4 extremities in NAD.
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Pulm: coarse BS throughout, no wheezes or crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B, no edema
Neuro: pt too lethargic to cooperate; moving all extremities
spontaneously and follows basic commands

Pertinent Results:
Initial chest x-ray.
1. Endotracheal tube properly positioned with tip at the
thoracic inlet.

2. Findings consistent with severe pulmonary edema with possibly
etiologies including congestive failure or, less likely, ARDS.

[**2115-12-4**] chest x-ray.
Resolution pulmonary edema

Initial chest CT.
There is an endotracheal tube in place. The airways are patent.
There is no pericardial effusion. There are no filling defects
in the pulmonary arterial vasculature. No pulmonary embolism is
identified. Some calcifications are seen in the coronary
arteries, the aortic arch and descending aorta. Otherwise, the
heart and great vessels are unremarkable. There is mild
bilateral pleural effusion. There is no axillary
lymphadenopathy. There is a precarinal 16 x 17-mm lymph node.

Interval increase in size in the spiculated mass located in the
right upper lobe measuring now 34 x 24 mm concerning for lung
cancer. New extensive patchy areas of ground-glass opacities are
seen throughout the lungs, mostly compromising the upper lobes .

Limited images of the upper abdomen did not demonstrate
significant abnormalities.

BONE WINDOWS: There are no concerning bone lesions.

CT RECONSTRUCTIONS: Confirmed the findings in the axial images.

IMPRESSION:
1. No evidence of pulmonary embolism.

2. Diffuse ground-glass opacities through the lung parenchyma,
concerning for PCP or pulmonary interstitial lymphoma with
underlying probable lung cancer in the right upper lobe.

3. Bilateral pleural effusion.


Brief Hospital Course:
This is a 69 year old woman with HIV on HAART (last CD4 940),
CHF (EF 50%) COPD, eosinophilic pneumonia, prior DVT and PE on
coumadin, and ESRD on HD who presented to this hospital on
[**11-28**] for 2 dyspnea and was found on arrival to be in acute
respiratory distress.  She was intubated immediately and placed
on CMV ventilation.  Of note the patient also became hypotensive
soon after a propofol drip was started for sedation. Propofol
was then discontinued, and levophed was added, resulting in
increased BP to 118/55.  The initial chest x-ray was concerning
for PNA as diffuse interstitial infiltrates were visualized.
The pt was admittted to the MICU and was treated empirically
with broad spectrum antibiotics along with hydrocortisone for
possible COPD exacerbation. In the MICU the pt was weaned off
pressors fairly quickly, extubated by hospital day 2, and was
subsequently transferred to the floor.  It was believed that her
respiratory distresss had a large component secondary to fluid
overload which was treated by hemodialysis.  She underwent
several rounds of ultrafiltration in addition to her regular
hemodialysis which resulted in improvement of her volume status
as evidenced by her improvement in respiratory status, her
physical exam, and by resolution of pulmonary edema on chest
x-ray.

Her course on the medical [**Hospital1 **] was complicated only by one
episode of chest pain that was not associated with EKG changes
and for which she ruled out for MI by cardiac enzymes.  As her
admission INR was subtherapeutic, she was maintained on a
heparin drip along with coumadin for her history of DVT and PE
until therapeutic INR was reachieved.  Her hospital course on
the [**Hospital1 **] was otherwise unremarkable.  She was discharged
breathing normally on room air and with instructions to finish
her empiric course of antibiotics.

Of note, review of her chest CT scan with the pulmonary service
revealed that a previously noted mass in the right upper lobe
had increased in size in comparison to a chest CT performed 3
months ago.  This raised concern that this mass may be
malignant.  She was to follow up with the pulmonary service
regarding this finding.

In summary, this is a 69 year old HIV positive woman on HAART
with CHF, COPD, ESRD on HD, and history of DVT and PE on
coumadin who was admitted in respiratory failure, intubated
briefly and treated empirically for pneumonia with broad
spectrum antibiotics, for COPD exacerbation with steroids, and
with hemodialysis for evidence of CHF exacerbation.  Her
respiratory status satisfactorily improved with these treatments
and it was felt that her presentation was largely secondary to
volume overload from CHF exacerbation.

Issues and plan arising from this hospitalization.

1. Pneumonia/Resp failure: Hypoxic respiratory failure now seems
to have been from pulmonary edema from CHF exacerbation.
Contriubtion from pneumonia/reactive airway disease and
eosinophilic PNA also possible. Status post extubation [**11-29**],
doing well.
- breathing improved well with serial ultrafiltration sessions
along with dialysis.  Pt to continue regular dialysis sessions
as outpatient.
- question PNA; although no source was identified, pan cultures
were unrevealing, Pt received empiric 10 day course of
levofloxacin, flagyl, and vancomycin (start [**11-28**])
- AFB smear negative, PCP negative
[**Name Initial (PRE) **] serum CMV IgG positive, IgM negative suggesting no recent
exposure.
.
3. COPD: Has required intubation in past for COPD.  Initially
received high dose steroids which were tapered down to her home
dose
- continue atrovent/albuterol nebulizers.
- on prednisone taper to 10 tomorrow.
.
4. Hypotension: Had brief pressor requirement, prior hypotensive
episode likely secondary to propofal along with sepsis. Now
blood pressure nl without pressor requirement.
-Initially held metoprolol, lisinopril 2.5 q day and Isordil 10
[**Hospital1 **].  Restarted these by discharge.
.
5. CAD/ Episode. Pt with known CAD s/p p NSTEMI [**5-19**], s/p
PTCA/stent LCX [**2113**]. Latest catheterization in [**10-21**] with
2-vessel disease. CP now resolved, no EKG changes or new
elevation in CE, pt was ruled out for MI.
-continue ASA 325
-restarted metoprolol and titrated up until rate control was
optimized
-continue imdur and lisinopril as outpatient.
.
6. ESRD on HD (M,W,F), her CHF exacerbation and fluid status
were largely managed by hemodialysis and additional
ultrafiltration sessions.
-Pt to continue regular HD schedule as outpatient.
.
6. HIV: CDR count 253; previous CD4 count 900s 3 months ago on
HAART. Unclear compliance with meds but pt says she has been
taking them.
- HIV viral load undetectable
- cont zidovudine, nevirapine, lamivudine
.
7. Eosinophilic PNA: CT findings suggestive of infection but
different from previous studies.
- continued home dose ofsteroids prednisone to taper.
.
8. H/O DVT, possible oncompliance given INR was 1 on admission.
No PE on CTA.
- pt was successfully bridged with heparin and discharged on
coumadin with therapeutic INR
.
9. DM2: controlled with sliding scale with NPH while in
hospital.
.
10. FEN:
- [**Doctor First Name **], heart healthy, renal diet
- lytes repleted cautiously given renal status.

11. Prophylaxis included heparin/coumadin, protonix
.
12. Access: R subclavian IJ placed [**11-28**], discontinued by
discharge.
.
13. Contact: [**Name (NI) **] [**Last Name (NamePattern1) 42692**] (daughter) is HCP [**Telephone/Fax (1) 101301**] (H),
[**Telephone/Fax (1) 101302**] (W)
.
Code status remains full.

Medications on Admission:
Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q 4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
Coumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution [**Hospital1 **]: As decided at dialysis
  Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 q day
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 q day
Isordil 10 [**Hospital1 **]

Discharge Medications:
1. Prednisone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Zidovudine 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
3. Nevirapine 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Lamivudine 100 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Vancomycin in Dextrose 1 g/200 mL Piggyback [**Last Name (STitle) **]: One (1) gram
Intravenous  X1 (ONE TIME) for 1 doses: Please give one more
vancomycin treatment during next dialysis session.
Disp:*1 gram* Refills:*0*
8. Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet,
Sublingual Sublingual Q5MIN X 3 () as needed for prn pain: Take
1 pill for chest pain, if no relief after 5 min take another, if
still no relief after 5 min take one more; seek medical
attention.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**1-20**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 solution* Refills:*1*
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
[**Month/Day (2) **]: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
13. Loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*120 Capsule(s)* Refills:*1*
14. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) inhalattion
Inhalation Q4H (every 4 hours) as needed.
Disp:*30 inhalattion* Refills:*0*
15. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Month/Day (2) **]: One (1)
Tablet PO QHD (each hemodialysis).
Disp:*30 Tablet(s)* Refills:*2*
16. Metronidazole 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a
day for 3 days: Total course is 10 days, day 1 is [**2115-11-28**].
Disp:*6 Tablet(s)* Refills:*0*
17. Levofloxacin 250 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
other day for 3 days: A total course  of 10 days, day 1 is
[**2115-11-28**].
Disp:*2 Tablet(s)* Refills:*0*
18. Calcium Acetate 667 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*2*
19. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day/Year **]: Two (2)
Tablet, Chewable PO QID (4 times a day) as needed.
20. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
21. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) inhalation
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 solution* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
Uphams Corner Home Care

Discharge Diagnosis:
Hypoxic respiratory failure.
Congestive heart failure exacerbation.
Possible pneumonia
Non cardiac chest pain.
Fluid overload
R middle lobe mass in lung of unknown etiology

Discharge Condition:
Good, breathing normally on room air.  Chest pain free.  Able to
tolerate solid food.  Appropriately anticoagulated.

Discharge Instructions:
Please return to hospital if you start to experience chest pain
or if you feel you it is gettting difficult to breathe.

Please continue to attend all of your hemodialysis regimen.

Please continue all medications prescribed in hospital, please
note you are taking 7.5 mg of coumadin at night.  Please note
you are now taking 10 mg of prednisone every day.

Please note you will be taking levoquine and flagyl until
[**2115-12-7**].

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 778**] Clinic on
[**2115-12-10**] at 11:15 AM. (Phone number is [**Telephone/Fax (1) 2393**]).

Please follow up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] on [**12-23**], [**2115**] at 4:30 pm their number is [**Telephone/Fax (1) 55570**].  You will
receive

Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4174**], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2115-12-18**]
1:15
Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2115-12-23**] 4:30
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2116-9-17**] 1:15
{'Acute respiratory failure,Congestive heart failure, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Acidosis,Acute kidney failure, unspecified,Mitral valve disorders,End stage renal disease,Diseases of tricuspid valve,Chronic airway obstruction, not elsewhere classified,Anemia in chronic kidney disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,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: Dyspnea

PRESENT ILLNESS: HPI:  69-yo-woman w/ HIV, COPD, ESRD on HD presents w/ shortness
of breath x 2 hours.  She reportedly was feeling well until 7pm,
when she developed dyspnea at rest.  The dyspnea became
progressively worse over the next 2 hours, prompting
presentation to the ED.  The pt did not complain of any fever,
chills, increased cough, chest pain, abd pain, melena, or
hematochezia.  On arrival in the ED, her  temp 103, HR 162, BP
230/104, RR 38.  She was in acute resp distress and was
intubated immediately and placed on CMV ventilation.  Propofol
gtt was started for sedation, resulting in decreased BP to
70/42.  Propofol was then d/c, and levophed was added, resulting
in increased BP to 118/55.  Initial CXR was concerning for PNA
w/ diffuse interstitial infiltrates, and the pt was treated w/
levo/vanco/ flagyl/bactrim/hydrocortisone.  The MICU team was
then called for further evaluation.

MEDICAL HISTORY: Past Medical History:
1. CAD s/p NSTEMI [**5-19**], s/p PTCA/stent LCX [**2113**]. Latest
catheterization in [**10-21**] with 2-vessel disease. Persantine MIBI
[**4-22**] without symptoms or EKG changes. MIBI images significant
for severe fixed inferior defect, EF 58%.
2. DM type 2, on NPH.
3. HIV, last CD4 count 940 in [**7-/2115**]
4. ESRD on HD since '[**10**] (M, W, F)
5. CHF, with mixed systolic (EF 45-50%) and diastolic
dysfunction.
6. Severe mitral regurgitation [**2115-6-20**]
7. History of RUL segmental PE in [**11/2114**], on coumadin
([**2114-12-5**]) D/C'd in 06/[**2115**].
8. Recently diagnosed right popliteal DVT [**7-/2115**], restarted on
Coumadin
9. H/o multiple AVF clots, s/p thrombectomies, last in [**2115-1-8**]
9. H/o GIB in the setting of coagulopathy and NSAIDs
10. Eosinophilic pneumonia diagnosed [**4-22**], on chronic
prednisone therapy.
11. Anemia [**2-20**] CRF
12. Vulvar intraepithelial neoplasia diagnosed in [**2113-4-18**].
13. COPD with PFTs with FVC 0.69 (27%), FEV1 0.46 (24%),
FEV1/FVC 92%.
14. History of positive Galactomannan antigen
15. RUL nodules on CT, not FDG avid on PET on [**8-20**]. Etiology
unclear.
16. Vulvar squamous cell carcinoma in situ.

MEDICATION ON ADMISSION: Bactrim 80-400 mg q M/W/Fri
Prednisone 20 mg qd (to be tapered slowly)
B Complex-Vitamin C-Folic Acid 1 mg qd
Zidovudine 200 [**Hospital1 **]
Nevirapine 200 [**Hospital1 **]
Lamivudine 100 qd
Docusate Sodium 100 mg [**Hospital1 **]
Pantoprazole 40 q 24
Albuterol q 4 prn
Albuterol-Ipratropium q6
Hydromorphone 4 mg Q3-4H prn
Calcium Carbonate 500 tid
Oxycontin 10 mg q12 hr
Senna 8.6 [**Hospital1 **] prn
Epogen inj
Coumadin 2.5 qhs
Paricalcitol 5 mcg/mL Solution [**Hospital1 **]: As decided at dialysis
  Intravenous 3X/WEEK (MO,WE,FR).
NPH 20 units qam, with regular sliding scale twice a day
ASA 325 q day
Metoprolol 25 [**Hospital1 **]
Lisinopril 2.5 q day
Isordil 10 [**Hospital1 **]

ALLERGIES: Motrin / Lipitor

PHYSICAL EXAM: On admission to MICU:
PE:  T 103, HR 112, BP 118/55, O2 sat 100% CMV 500 x 12/40%/5
Gen: chronically ill appearing woman lying flat in bed,
intubated, moving all 4 extremities in NAD.
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no JVD
CV: reg s1/s2, no s3/s4/m/r
Pulm: coarse BS throughout, no wheezes or crackles
Abd: obese, +BS, soft, NT, ND
Ext: warm, 2+ DP B, no edema
Neuro: pt too lethargic to cooperate; moving all extremities
spontaneously and follows basic commands

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Recently was at the [**Hospital **] rehab. Lives in [**Location 686**] with her
daughter. [**Name (NI) **] EtOH. Ex-smoker (60 pack-year smoking history) 

### Response:
{'Acute respiratory failure,Congestive heart failure, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Acidosis,Acute kidney failure, unspecified,Mitral valve disorders,End stage renal disease,Diseases of tricuspid valve,Chronic airway obstruction, not elsewhere classified,Anemia in chronic kidney disease,Asymptomatic human immunodeficiency virus [HIV] infection status,Coronary atherosclerosis of native coronary artery,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
