CHIEF COMPLAINT: shortness of breath, cough, lower extremity swelling

PRESENT ILLNESS: 87 yo Russian speaking female with hx of dCHF, Aortic and mitral
valve replacements for rheumatic fever, and recent admission for
samonella bactermia, now with worsening dyspnea. Pt was at rehab
and has been haivng increasing fluid retention despite
excalation of lasix and addtion of metolazone. She was sent from
rehab for admission for HF. She has 2 pillow orthopnea. Has been
SOB per daughter and has chronic intermitent angina pains. Also
been having a non-productive cough. Last BM was today, but has
RUQ pain. No urinary sx. Now using oxygen which she does not at
baseline.
.
On arrival VS were 98.8 62 144/62q 22 100. Labs showed proBNP:
3535.
CXR showed increase in pulm edema. EKG showed AV paced,
unchanged at rate of 60. Pt was given lasix 60 IV x 1. ASA
325mg. VS on transfer are 97.7 61 112/66 18 98% 4L.

MEDICAL HISTORY: 1. Coronary artery disease status post 1 vessel CABG
2. Rheumatic heart disease status post prosthetic aortic and
mitral replacement in [**2122**].
3. Pulmonary hypertension
4. Insulin dependent diabetes mellitus
5. Chronic renal insufficiency (baseline creatinine 1.7-2.0)
6. Atrial fibrillation status post ablation and pacemaker
implantation for tachy brady on coumadin for anticogulation.
7. Cholelithiasis that was previously symptomatic but had
declined surgical intervention.
8. Nephrolithiasis.
9. Spinal stenosis.
10. h/o esophogeal candidiasis
11. HTN
12. HL
13. Anemia (Fe deficiency), requiring tranfusions
14. Recent Hx of falls

MEDICATION ON ADMISSION: Maalox Q6H PRN
Amiodarone 200mg qday
Simvastatin 20mg HS
Calcium Acetate 667mg x 2 TID
Sarna lotion Q6H PRN
Ceftriaxone - completed [**3-22**]
Colace 200mg [**Hospital1 **]
Epo 5000units Q5days
Fluconazole 100mg Q48H, still on from last admission
Lasix 80mg [**Hospital1 **]
Metolozone 5mg qday
Insulin lantus 30 units Qday
Isosorbide Mononitrate 90mg qday
Levothryroxine 37.5mcg qday
Lidocaine 2% solution PRN
Metoprolol 25mg [**Hospital1 **]
Nitro 0.4mg SL PRN
Protonix 40mg Qday
Polysaccaride Iron Complex 150 Qday
KCl 40meq per day
Ranitidine 150mg [**Hospital1 **]
Senna 17.2mg [**Hospital1 **] PRN
Spironolactone 25mg qday
SSI
Trazadone prn
Bisacodyl prn
Coumadin 2mg PM

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 96.5 123/53 60 22 100%2l FS 167
General: Alert, oriented, appears in some discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to above jawline, no LAD
Lungs: crackles at bases, poor airmovement at bases
CV: Regular rate and rhythm, click of heart valve, systolic
murmur throughout chest, [**4-10**]
Abdomen: soft, tender in RUQ, mild distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, 3+ pitting
edema up to sacrum
Neuro: awake, hard of hearing, cooperative, moving all
extremities

FAMILY HISTORY: Father had DM
Mother had CHF
There is a family history of hypertension, and cardiac disease.

SOCIAL HISTORY: Has been at rehab recently. Prior to this was living alone. Uses
a walker. Last fall was a few months ago. No etoh, tobacco, or
drugs.
Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Candidal esophagitis,Paroxysmal ventricular tachycardia,Intestinal infection due to Clostridium difficile,Acidosis,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other and unspecified ovarian cyst,Other and unspecified angina pectoris,Cardiac pacemaker in situ,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Other chronic pulmonary heart diseases,Aortocoronary bypass status,Abnormal coagulation profile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified acquired hypothyroidism,Insomnia, unspecified,Anticoagulants causing adverse effects in therapeutic use
Ac on chr diast hrt fail,Acute kidney failure NOS,Septicemia NOS,Severe sepsis,Candidal esophagitis,Parox ventric tachycard,Int inf clstrdium dfcile,Acidosis,Gstr/ddnts NOS w/o hmrhg,Ovarian cyst NEC/NOS,Angina pectoris NEC/NOS,Status cardiac pacemaker,Chronic kidney dis NOS,Long-term use of insulin,DMII wo cmp nt st uncntr,Heart valve replac NEC,Chr pulmon heart dis NEC,Aortocoronary bypass,Abnrml coagultion prfile,Hy kid NOS w cr kid I-IV,Hyperlipidemia NEC/NOS,Anemia in chr kidney dis,Cholelithiasis NOS,Hypothyroidism NOS,Insomnia NOS,Adv eff anticoagulants
Admission Date:  [**2134-3-29**]              Discharge Date:   [**2134-4-12**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2356**]
Chief Complaint:
shortness of breath, cough, lower extremity swelling

Major Surgical or Invasive Procedure:
Blood transfusion

History of Present Illness:
87 yo Russian speaking female with hx of dCHF, Aortic and mitral
valve replacements for rheumatic fever, and recent admission for
samonella bactermia, now with worsening dyspnea. Pt was at rehab
and has been haivng increasing fluid retention despite
excalation of lasix and addtion of metolazone. She was sent from
rehab for admission for HF. She has 2 pillow orthopnea. Has been
SOB per daughter and has chronic intermitent angina pains. Also
been having a non-productive cough. Last BM was today, but has
RUQ pain. No urinary sx. Now using oxygen which she does not at
baseline.
.
On arrival VS were 98.8 62 144/62q 22 100. Labs showed proBNP:
3535.
CXR showed increase in pulm edema. EKG showed AV paced,
unchanged at rate of 60. Pt was given lasix 60 IV x 1. ASA
325mg. VS on transfer are 97.7 61 112/66 18 98% 4L.


Past Medical History:
1. Coronary artery disease status post 1 vessel CABG
2. Rheumatic heart disease status post prosthetic aortic and
mitral replacement in [**2122**].
3. Pulmonary hypertension
4. Insulin dependent diabetes mellitus
5. Chronic renal insufficiency (baseline creatinine 1.7-2.0)
6. Atrial fibrillation status post ablation and pacemaker
implantation for tachy brady on coumadin for anticogulation.
7. Cholelithiasis that was previously symptomatic but had
declined surgical intervention.
8. Nephrolithiasis.
9. Spinal stenosis.
10. h/o esophogeal candidiasis
11. HTN
12. HL
13. Anemia (Fe deficiency), requiring tranfusions
14. Recent Hx of falls


Social History:
Has been at rehab recently. Prior to this was living alone. Uses
a walker. Last fall was a few months ago. No etoh, tobacco, or
drugs.

Family History:
Father had DM
Mother had CHF
There is a family history of hypertension, and cardiac disease.



Physical Exam:
Vitals: 96.5 123/53 60 22 100%2l FS 167
General: Alert, oriented, appears in some discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to above jawline, no LAD
Lungs: crackles at bases, poor airmovement at bases
CV: Regular rate and rhythm, click of heart valve, systolic
murmur throughout chest, [**4-10**]
Abdomen: soft, tender in RUQ, mild distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, 3+ pitting
edema up to sacrum
Neuro: awake, hard of hearing, cooperative, moving all
extremities


Pertinent Results:
CXR [**2134-3-29**]: IMPRESSION: Mild CHF with right fissural fluid and
left pleural effusion, similar to prior study.

[**2134-3-29**] 05:30PM BLOOD WBC-4.4 RBC-2.79* Hgb-8.2* Hct-27.0*
MCV-97 MCH-29.5 MCHC-30.4* RDW-20.5* Plt Ct-194#
[**2134-4-1**] 06:45AM BLOOD WBC-9.5# RBC-2.66* Hgb-7.7* Hct-25.4*
MCV-96 MCH-28.8 MCHC-30.1* RDW-20.4* Plt Ct-200
[**2134-3-29**] 06:17PM BLOOD PT-19.8* PTT-33.2 INR(PT)-1.8*
[**2134-4-1**] 06:45AM BLOOD PT-19.4* PTT-32.7 INR(PT)-1.8*
[**2134-3-29**] 05:30PM BLOOD Glucose-170* UreaN-83* Creat-2.2* Na-134
K-5.9* Cl-95* HCO3-32 AnGap-13
[**2134-4-1**] 06:45AM BLOOD Glucose-136* UreaN-88* Creat-2.2* Na-136
K-3.5 Cl-92* HCO3-33* AnGap-15
[**2134-3-29**] 05:30PM BLOOD ALT-19 AST-78* LD(LDH)-818* CK(CPK)-67
AlkPhos-304* TotBili-0.4
[**2134-4-1**] 06:45AM BLOOD ALT-12 AST-26 LD(LDH)-235 AlkPhos-291*
TotBili-0.5
[**2134-3-29**] 05:30PM BLOOD CK-MB-NotDone proBNP-3535*
[**2134-3-29**] 05:30PM BLOOD cTropnT-0.05*
[**2134-3-31**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2134-3-31**] 12:50PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2134-3-29**] 05:30PM BLOOD ALT-19 AST-78* LD(LDH)-818* CK(CPK)-67
AlkPhos-304* TotBili-0.4
[**2134-3-31**] 06:00AM BLOOD CK(CPK)-33
[**2134-3-31**] 12:50PM BLOOD CK(CPK)-35
[**2134-3-30**] 12:03AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.7*
[**2134-3-31**] 06:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.6
.
Imaging:
CXR [**3-29**]:  Mild CHF with right fissural fluid and left pleural
effusion, similar to prior study.
CXR [**4-1**]: 1. New mild pulmonary edema. Stable small pleural
effusions and mild cardiomegaly.
2. No evidence of pneumonia.
CXR [**4-3**]: Mild pulmonary edema is worsened on the right,
improved slightly on the left, moderate right and small left
pleural effusions have substantially increased, particularly the
right. Moderate cardiac enlargement is longstanding. The patient
has prior mitral and aortic valve replacement, congenital right
aortic arch. Transvenous right atrial and right ventricular
pacer leads are unchanged in standard placements. No
pneumothorax.
.
Liver/GB U/S [**4-3**]: 1. Simple cholelithiasis without acute
cholecystitis.
2. Unchanged dilated CBD measure up to 12 mm.
3. Unchanged dilated hepatic veins.
4. Small amount of ascites and bilateral pleural effusions.
.
Pelvic U/S [**4-7**]: 1. 6.5 cm left adnexal cystic lesion only
minimally increased in size compared to [**2130**] with no concerning
features
2. Trace free pelvic fluid.
.
Humerus Xray [**4-10**]: Again noted is a supracondylar fracture with
increased resorption at the fracture site. There is no
radiographic finding to suggest [**Hospital1 **] at this time. There is
approximately 7-mm gap at the medial fracture on the external
rotation view.
.
KUB [**4-10**]: Four total images are submitted. These are somewhat
limited on the basis of technique and patient positioning, but
are the best images are available, given these limitations.
Dual-lead pacemaker and valvular prosthesis again identified.
There is a large amount of stool throughout the colon. No
discrete obstruction is identified. Air-filled small bowel is
also identified, but this does not appear to be pathologically
dilated at this time.
.
EKGs:
[**3-29**]: A-V sequential pacing. Since the previous tracing of
[**2134-3-13**] changes in early precordial QRS voltage is of uncertain
significance. Clinical correlation is suggested.
[**4-2**]: A-V sequentially paced rhythm and intermittent ventricular
pacing. Compared to the previous tracing of [**2134-3-31**] atrial
pacemaker activiy is now recorded.
[**4-6**]:Probably both sinus and atrial pacing with at least one
atrial premature beat. There is ventricular pacing throughout.
Since the previous tracing of [**2134-4-2**] the atrial rate is faster.
Clinical correlation is suggested.
[**4-8**]: Sinus rhythm competing with atrial pacing with ventricular
pacing. Compared to the previous tracing there is no significant
change.
.
.
Labs:
........................WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2134-4-12**] 08:44AM    6.2 2.96* 8.9* 28.7* 97 30.2 31.2 19.6*
214
[**2134-4-11**] 07:50AM    5.8 2.84* 8.5* 26.7* 94 29.9 31.9 19.9*
203
[**2134-4-10**] 07:45AM    6.5 2.94* 9.0* 28.6* 97 30.7 31.6 20.0*
234
[**2134-4-9**] 08:40AM    5.2 2.98* 8.7* 28.0* 94 29.3 31.0 20.1*
221
[**2134-4-8**] 07:46PM    5.2 2.98* 9.0* 28.0* 94 30.3 32.2 19.6*
207
[**2134-4-8**] 08:10AM    5.2 3.18* 9.2* 30.2* 95 28.9 30.5* 19.7*
226
.
.
......................Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2134-4-12**] 08:44AM    108* 56* 1.6* 139 4.9 100 33* 11
[**2134-4-11**] 07:50AM    103* 58* 1.4* 141 3.9 101 31 13
[**2134-4-10**] 07:45AM    237* 64* 1.6* 139 3.8 100 29 14
[**2134-4-9**] 08:40AM    153* 72* 1.7* 140 3.7 100 31 13
[**2134-4-8**] 08:10AM    296* 74* 1.8* 137 3.6 97 31 13
[**2134-4-7**] 07:15AM    206* 78* 2.0* 135 3.9 96 29 14
[**2134-4-6**] 07:50AM    294* 83* 2.1* 134 4.3 97 27 14
.
.
...........................Calcium Phos Mg
[**2134-4-12**] 08:44AM          9.0 3.1 2.0
[**2134-4-11**] 07:50AM          8.8 2.3* 2.0
[**2134-4-10**] 07:45AM          8.9 2.4* 2.4
[**2134-4-9**] 08:40AM          8.5 2.1* 2.1
[**2134-4-8**] 08:10AM          8.8 2.3* 2.3
[**2134-4-7**] 07:15AM          8.7 2.7 2.4
[**2134-4-6**] 07:50AM          8.1* 3.7 2.5
[**2134-4-5**] 05:24AM          8.0* 4.0 2.6


Brief Hospital Course:
87 yo F with hx of dCHF, AVR, MRV, DMII, recent bacteremia, here
with worsening dyspnea and concern for acute on chronic dHF.

# Acute on chronic dCHF: In the setting of recent
hospitalization for bacteremia, during which time the patient
had IVF's and less diuretics. On admission, the patient had
bilateral pitting edema to the sacrum and pulmonary rales. She
was given Aldactone & IV Lasix PRN with good diuresis. Her
electrolytes were carefully monitored and repleted [**Hospital1 **]. She was
maintained on a low salt diet and a 1500ml fluid restriction. On
HD #5, she had a hypotensive event in the morning which was
triggered - she got a fluid bolus and then was maintained on
continuous IVF. Later that day she was found to be unresponsive
with a run of torsades. A code was called, but this event was
self-limited and the patient re-gained pulses. She was sent to
the MICU. EP saw her, discussion below. She had intermittent
chest pain without EKG changes or enzyme leak in the MICU, which
was controlled with nitro/morphine. She was ultimately
transferred out of the MICU after 3 nights. Her fluid status
kept even, and she did have some swelling of her LEs on Lasix.
She was given prn lasix, and her daily diuretic was changed to
Bumex 2 mg [**Hospital1 **]. By day of discharge she had clear lungs on exam
with decreased LE swelling. She continued to have occasional
bouts of intermittent chest pain without EKG changes or
telemetry events, which was controlled with SL nitroglycerine.
She was continued on her CCB, Imdur and her statin.
.
# C. difficile colitis: Patient with leukocytosis & fever to 101
on HD 5. She was started empirically on Flagyl for presumed C.
diff in the context of completing 2 week antibiotic course and
ID was consulted to determine whether she required additional
coverage for Salmonella. They recommended that she remain on
monotherapy with Flagyl, but the patient's condition continued
to deteriorate requiring a ICU transfer (see above). Her C. diff
toxin returned positive in the interim and her coverage was
broadened to Vancomycin/Flagyl. However, given the concern of
medications that might prolong the QT interval, she was switched
to monotherapy PO Vancomycin per ID recommendations. She was
transferred to the floor on this medication. ID requested a
pelvic ultrasound given a finding of adnexal cyst on her CT from
her early [**Month (only) **] admission and low possibility that this could be a
site of infection; this was done and she had small interval
increase in size from previous study in [**2130**] but no change in
morphology or other concerning characteristics. She is to
continue on Vancomycin for two weeks total (day 1 = [**4-2**]). She
continued to have a moderate amount of diarrhea and occasional
blood in her stool, likely related to an elevated INR (see
below). She did have a somewhat distended abdomen on exam but
did not have point tenderness, rebound, guarding, and was not
tympanic. She had occasional complaints of abdominal pain but in
general these were of short duration and responded well to
Maalox/lidocaine. She was started on Sucralfate for suspected
gastritis. A KUB was done on [**4-10**] with a read of "There is a
large amount of stool throughout the colon. No discrete
obstruction is identified. Air-filled small bowel is also
identified, but this does not appear to be pathologically
dilated at this time." A KUB was repeated on [**4-12**] and was read as
stool in the colon without any signs of pneumoperitoneum or
bowel obstruction. The patient will need to continue on a bowel
regimen.
.
# Acute on Chronic renal failure: Creatinine remained stable at
her baseline throughout her stay on the medicine floor despite
receiving Lasix. She did receive several extra doses of lasix
related to fluid overload following her MICU stay. Her diuretic
was changed to Bumex. Spironolactone was continued. Her
electrolytes were followed and repleted as necessary.

# DMII: Patient maintained on a fixed dose & insulin sliding
scale throughout this hospitalization. [**Last Name (un) **] diabetes center
was consulted and made recommendations regarding her insulin
doses.

# h/o Atrial Fibrillation: Patient is AV paced at 60bpm; she
initially remained in NSR during this hospitalization. She was
on her home Amiodarone & Metoprolol. On [**4-2**], she had an episode
of Torsades and a code blue was called, as discussed above. She
returned to a perfusing rhythm. EP saw the patient and
interrogated her pacemaker and confirmed Torsades. She had an
EKG after event without evidence of ischemia. Notably, her
baseline EKG had a long QT. She was evaluated for any
QT-prolonging medications; these included amiodarone and
fluconazole (which had been continued from her previous
admission for concern over [**Female First Name (un) **] esophagitis). Her amiodarone
and metoprolol were held. EP increased her baseline HR to
decrease her QT. Her troponins were cycled and were negative.
She had been started on Flagyl briefly for Salmonella, but this
was discontinued given its possible QT effects. Following
transfer to the floor, she had no further events on telemetry.
Several repeat EKGs were done and these demonstrated gradual
resolution of the prolonged QTc (487 msec to 473 msec). Final
EKG done before discharge was stable.
.
# Hx of Rheumatic Fever s/p AVR/MVR: Goal INR 2.5-3.5, with
history of very poorly maintained INR's. Patient's INR was
subtherapeutic on admission and she was temporarily placed on a
Heparin gtt to Coumadin, but this was stopped at the preference
of her family given prior episodes of bleeding on Heparin. Her
home Coumadin dose was temporarily increased to 5mg daily and
then titrated down to 3mg daily with a therapeutic INR reached
on HD 5. She was also placed on pneumoboots for DVT prophylaxis.
In the MICU, her INR was supratherapeutic and was held. She had
a nosebleed, and received vitamin K. Prior to transfer back to
the floor, she was re-started on her coumadin, and the family
agreed to heparin bridge. This was stopped after her INR came up
to 2.5. She again became supratherapeutic, and her coumadin was
again held. It was restarted on [**4-10**] at 2 mg daily. Her INR was
2.6 on the day of discharge.
.
# Esophagitis: Patient with a diagnosis of esophageal
candidiasis on last admission, treated with 3 weeks of
Fluconazole that was completed on re-admission. She demonstrated
no evidence of persistent infection during this hospitalization,
but she was continued on her home PPI as well Tessilon Perles &
Cepacol lozenges for ongoing cough. The fluconazole was stopped
as above. She did have some throat pain after transfer back from
the MICU and was given Maalox/Lidocaine with generally good
relief.
.
# Elevated LFTs: Patient admitted with elevated Alkaline
phosphatase, AST, & GGT, normal bilirubin. Initially, she c/o
RUQ pain on exam, but refused RUQ ultrasound.  Her LFT's were
monitored given her history of Salmonella, but all levels
normalized on HD4 except the patient's Alkaline phosphatase. She
did not have pain that was localized to the RUQ but did have
occasional vague abdominal pain that was improved with maalox,
sucralfate, and tylenol as above. Her KUBs were significant for
possible constipation and her laxatives were re-started.
.
# Hypothyroid: Patient's TSH was 6.3 during this
hospitalization. Prior free T4 obtained within the last 6 months
was within normal limits She was maintained on 37.5mcg daily.
.
# Insomnia: The patient came in on report that she received
trazadone prn for insomnia, but this was tried with negative
effects (daughter reported that patient had hallucinations).
Trazadone was stopped. The patient was given Alprazolam prn for
her anxiety and insomnia.
.
# Code: Patient was FULL CODE on admission, but on [**4-2**], after
Torsades, patient's family decided to change her code status to
DNR/DNI
.
# Emergency Contact: Daughter, [**Name (NI) 8463**] [**Telephone/Fax (1) 103841**]

Medications on Admission:
Maalox Q6H PRN
Amiodarone 200mg qday
Simvastatin 20mg HS
Calcium Acetate 667mg x 2 TID
Sarna lotion Q6H PRN
Ceftriaxone - completed [**3-22**]
Colace 200mg [**Hospital1 **]
Epo 5000units Q5days
Fluconazole 100mg Q48H, still on from last admission
Lasix 80mg [**Hospital1 **]
Metolozone 5mg qday
Insulin lantus 30 units Qday
Isosorbide Mononitrate 90mg qday
Levothryroxine 37.5mcg qday
Lidocaine 2% solution PRN
Metoprolol 25mg [**Hospital1 **]
Nitro 0.4mg SL PRN
Protonix 40mg Qday
Polysaccaride Iron Complex 150 Qday
KCl 40meq per day
Ranitidine 150mg [**Hospital1 **]
Senna 17.2mg [**Hospital1 **] PRN
Spironolactone 25mg qday
SSI
Trazadone prn
Bisacodyl prn
Coumadin 2mg PM


Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or fever.
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. Polyethylene Glycol 3350 17 gram Powder in Packet Sig: One
(1) packet PO BID (2 times a day) as needed for constipation.
7. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours)
as needed for pain.
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 5 days.
12. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
14. Maalox Advanced 200-200-20 mg/5 mL Suspension Sig: Fifteen
(15) ml PO three times a day as needed for cough, sore throat,
upset stomach.
15. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
16. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for dysphagia.
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for cough.
20. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
21. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
22. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
23. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for shortness of breath, cough, wheezing.
24. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
25. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at breakfast.
26. Humalog 100 unit/mL Solution Sig: 1-20 units Subcutaneous
with meals and at bedtime as needed for per insulin sliding
scale.
27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

28. Outpatient Lab Work
Please get daily INR and send to Dr.[**Name (NI) 15895**] office


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Primary: Acute on chronic diastolic heart failure exacerbation,
C. difficile enterocolitis, Torsades de Pointes

Secondary:
Diabetes
Chronic Kidney disease
Hypothyroidism

Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were admitted to the hospital for a heart failure
exacerbation. You had shortness of breath and fluid overload.
You were found to have an infection called C. difficile, which
affects your GI tract. We started treatment with multiple
antibiotics, including vancomycin and flagyl (metronidazole).
You were discharged on vancomycin, which you should take for 4
more days to complete the 14-day course.
.
You also had trouble with your heart rhythm while you were here,
and had an episode of very abnormal rhythm called "Torsades de
Pointes". We sent you to the intensive care unit for monitoring.
Several of your medications were stopped or changed. You were
then sent to the inpatient medicine floor.
.
On the inpatient medicine floor you had some abdominal pain, for
which we could not find a clear cause. We also had to modify
your coumadin regimen to get your INR to the right place. You
INR did become very high, and we suspect that this along with
the C. difficile colitis is the reason for you having had some
blood in your stool. You did have some abdominal pain likely
related to bowel movements, but this was generally short-lived
in duration and improved after taking Maalox or Tylenol. This
may also be related to constipation. We also started a lidocaine
patch on your arm for your known elbow fracture. This seemed to
help with the pain there. We did imaging studies of this arm,
and the fracture has still not healed; you should strongly
consider seeing your orthopedist for this as an outpatient. You
should also continue a bowel regimen so that you can clear some
of the stool from your colon.
.
.
Your home medications were changed as follows:
- CONTINUED Maalox Q6H PRN
- STOPPED Amiodarone 200mg qday
- CONTINUED Simvastatin 20mg HS
- CONTINUED Calcium Acetate 667mg x 2 TID
- CONTINUED Sarna lotion Q6H PRN
- STOPPED Ceftriaxone - completed [**3-22**]
- STOPPED Colace 200mg [**Hospital1 **]
- CHANGED Epo 5000units Q5days
- STOPPED Fluconazole 100mg Q48H
- STOPPED Lasix 80mg [**Hospital1 **]
- STOPPED Metolozone 5mg qday
- CONTINUED Insulin lantus 30 units Qday
- CONTINUED Isosorbide Mononitrate 90mg qday
- CONTINUED Levothryroxine 37.5mcg qday
- CONTINUED Lidocaine 2% solution PRN
- STOPPED Metoprolol 25mg [**Hospital1 **]
- CONTINUED Nitro 0.4mg SL PRN
- CHANGED Protonix 40mg Qday to Omeprazole, which is a similar
drug
- STOPPED Polysaccaride Iron Complex 150 Qday
- STOPPED KCl 40meq per day
- STOPPED Ranitidine 150mg [**Hospital1 **]
- CONTINUED Senna 17.2mg [**Hospital1 **] PRN
- CONTINUED Spironolactone 25mg qday
- CONTINUED Humalog sliding scale
- STOPPED Trazadone prn
- CONTINUED Bisacodyl prn
- CONTINUED Coumadin 2mg PM
- STARTED Vancomycin
- STARTED Bumex
- STARTED Lidocaine patches
- STARTED Alprazolam (Xanax)
- STARTED Cepacol lozenges
- STARTED Sucralfate for upset stomach
- STARTED Polyethylene glycol for constipation

Followup Instructions:
Please call for follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 1270**], at [**0-0-**].
.
You should consider making an appointment with your orthopedic
surgeon regarding your fracture.


                             [**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2362**]

Completed by:[**2134-4-12**]
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Candidal esophagitis,Paroxysmal ventricular tachycardia,Intestinal infection due to Clostridium difficile,Acidosis,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other and unspecified ovarian cyst,Other and unspecified angina pectoris,Cardiac pacemaker in situ,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Other chronic pulmonary heart diseases,Aortocoronary bypass status,Abnormal coagulation profile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified acquired hypothyroidism,Insomnia, unspecified,Anticoagulants causing adverse effects in therapeutic use'}


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, cough, lower extremity swelling

PRESENT ILLNESS: 87 yo Russian speaking female with hx of dCHF, Aortic and mitral
valve replacements for rheumatic fever, and recent admission for
samonella bactermia, now with worsening dyspnea. Pt was at rehab
and has been haivng increasing fluid retention despite
excalation of lasix and addtion of metolazone. She was sent from
rehab for admission for HF. She has 2 pillow orthopnea. Has been
SOB per daughter and has chronic intermitent angina pains. Also
been having a non-productive cough. Last BM was today, but has
RUQ pain. No urinary sx. Now using oxygen which she does not at
baseline.
.
On arrival VS were 98.8 62 144/62q 22 100. Labs showed proBNP:
3535.
CXR showed increase in pulm edema. EKG showed AV paced,
unchanged at rate of 60. Pt was given lasix 60 IV x 1. ASA
325mg. VS on transfer are 97.7 61 112/66 18 98% 4L.

MEDICAL HISTORY: 1. Coronary artery disease status post 1 vessel CABG
2. Rheumatic heart disease status post prosthetic aortic and
mitral replacement in [**2122**].
3. Pulmonary hypertension
4. Insulin dependent diabetes mellitus
5. Chronic renal insufficiency (baseline creatinine 1.7-2.0)
6. Atrial fibrillation status post ablation and pacemaker
implantation for tachy brady on coumadin for anticogulation.
7. Cholelithiasis that was previously symptomatic but had
declined surgical intervention.
8. Nephrolithiasis.
9. Spinal stenosis.
10. h/o esophogeal candidiasis
11. HTN
12. HL
13. Anemia (Fe deficiency), requiring tranfusions
14. Recent Hx of falls

MEDICATION ON ADMISSION: Maalox Q6H PRN
Amiodarone 200mg qday
Simvastatin 20mg HS
Calcium Acetate 667mg x 2 TID
Sarna lotion Q6H PRN
Ceftriaxone - completed [**3-22**]
Colace 200mg [**Hospital1 **]
Epo 5000units Q5days
Fluconazole 100mg Q48H, still on from last admission
Lasix 80mg [**Hospital1 **]
Metolozone 5mg qday
Insulin lantus 30 units Qday
Isosorbide Mononitrate 90mg qday
Levothryroxine 37.5mcg qday
Lidocaine 2% solution PRN
Metoprolol 25mg [**Hospital1 **]
Nitro 0.4mg SL PRN
Protonix 40mg Qday
Polysaccaride Iron Complex 150 Qday
KCl 40meq per day
Ranitidine 150mg [**Hospital1 **]
Senna 17.2mg [**Hospital1 **] PRN
Spironolactone 25mg qday
SSI
Trazadone prn
Bisacodyl prn
Coumadin 2mg PM

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 96.5 123/53 60 22 100%2l FS 167
General: Alert, oriented, appears in some discomfort
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to above jawline, no LAD
Lungs: crackles at bases, poor airmovement at bases
CV: Regular rate and rhythm, click of heart valve, systolic
murmur throughout chest, [**4-10**]
Abdomen: soft, tender in RUQ, mild distended, bowel sounds
present
Ext: Warm, well perfused, 2+ pulses, no clubbing, 3+ pitting
edema up to sacrum
Neuro: awake, hard of hearing, cooperative, moving all
extremities

FAMILY HISTORY: Father had DM
Mother had CHF
There is a family history of hypertension, and cardiac disease.

SOCIAL HISTORY: Has been at rehab recently. Prior to this was living alone. Uses
a walker. Last fall was a few months ago. No etoh, tobacco, or
drugs. 

### Response:
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Unspecified septicemia,Severe sepsis,Candidal esophagitis,Paroxysmal ventricular tachycardia,Intestinal infection due to Clostridium difficile,Acidosis,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other and unspecified ovarian cyst,Other and unspecified angina pectoris,Cardiac pacemaker in situ,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Heart valve replaced by other means,Other chronic pulmonary heart diseases,Aortocoronary bypass status,Abnormal coagulation profile,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Unspecified acquired hypothyroidism,Insomnia, unspecified,Anticoagulants causing adverse effects in therapeutic use'}
