CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: Pt is a 80 yo F with CAD s/precent DES to mid LCX and proximal
OM in [**3-/2197**], CRI (baseline Cr 2.1), afib not on coumadin,
multiple lung lesions on CT chest concerning for lung cancer,
DM2, and demetia who was transferred from OSH for respiratory
distress. Pt initially presented to OSH for depression as has
been at [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 33012**] unit since [**5-11**]. She was initially
started on avelox for RLL infiltrate on CXR and leukocytosis to
13. A rapid response team was called on [**5-21**] for mental status
changes, blood pressure of 90/40, HR 49, RR 20, O2 sat 79% on RA
improving to 100% with NRB. EKG showed sinus brady, no acute
ischmemic changes. BS was 248. IO was placed. Pt was acutely
agitated and required 2 mg IV haldol. She was transferred to the
ICU. During this time, she had coughed up a small amount of
stomach secretions. Antibiotics were changed to cefepime and
vancomycin. She was also given lasix 60 mg IV (previously
received IVFs for Na 122, Cr 2.9 from 2.0 on admission),
solumedrol 80 mg IV x1. She was also transfused 2 or 3 units
PRBCs for HCT 22.3 (from 31.1 on [**5-12**]) with IV lasix 20 mg. She
was having episodes of anxiety/agitation requiring haldol 2 mg
IV x2 and ativan 1 mg IV x2. ABG was 7.23/46/306.
.
At [**Hospital1 18**], pt was agitated on arrival, calmed with ativan 1 mg
x1. During episodes of agitation, pt would require NRB to keep
O2 sats in the mid-90s. Off NRB, O2 sat was in the 80s. This has
occurred 3-4 times today. Pt also required q4 nebulizers
(atrovent only). ABG was 7.37/39/65 on NRB. Pt also missed 2
doses of metoprolol, went into afib with RVR, which responded to
dilt 10 mg IV x2. SBP dipped to 90s with the dilt.
.
Pt unable to given an extensive ROS given delirium. Reported
terrible breathing. Denied CP, palpitation, nausea, abdominal
pain.

MEDICAL HISTORY: CAD (cath on [**2197-2-17**] showed 3VD, PCI to LCX and OM in [**2197-3-13**])
PAF (not anticoagulated)
CVA
Major depression with psychosis
Dementia
Hypertension
Hyperlipidemia
Hypothyroidism
DM2
CRI (baseline Cre 2.1-2.5)
Seizure disorder (unclear if ever had seizure per family)
PVD s/p femoral bypass and s/p bilateral CEA
h/o erosive gastritis on omeprazole
s/p cholecystectomy
s/p hysterectomy
Lung lesions suspicious for lung Ca
Recent strep bovis infection, colon biopsies showed adenoma.

MEDICATION ON ADMISSION: Metoprolol 100 mg TID
Methylphenidate 2.5 mg [**Hospital1 **]
Synthroid 75 mcg daily
Imdur 120 mg daily
hydralazine 75 mg daily
cilostazol 100 mg daily
atrovastatin 80 mg daily
Amldopine 15 mg daily
lorazepam 0.5 mg daily
Nexium 40 mg IV daily
Vancomycin 500 mg
Maxipime 1 gm
Solumedrol 80 mg IV x1
Plavix 75 mg daily
Glargine 20 units daily
citalopram 10 mg daily
ASA 81 mg daily
mirtazapine 15 mg daily
Tylenol 650 mg prn
Folic acid 1 mg daily
Nitroglycerin 0.4 mg prn
Lovenox 30 mg sq daily
Percocet 2 tablets q6 hr prn
Duoneb q4 prn
Lactulose prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 96 HR 84 (70-90) BP 130/48 (110-150/40-60) 18 97% on 40%
face tent
Gen: obese, elderly woman in NAD
HEENT: EOMI, PERRLA, mmm
CV: irregularly irregular II/VI systolic murmur heard best at
LLSB
Resp: CTAB anteriorly no wheeze or crackles
ABd: soft, NT, + bs, non-distended
Ext: 1 + pitting edema bilat LE
Neuro: A+Ox3, will not cooperate with the rest of exam

FAMILY HISTORY: No family history of early MI, mother died at 53 yo of unknown
primary cancer. Father died in 80s.

SOCIAL HISTORY: Former smoker (100 pk yr), quit '[**89**], rare EtOH. 3 daughters, was
living with daughter [**Name (NI) **], but more recently has been at [**First Name5 (NamePattern1) 392**]
[**Last Name (NamePattern1) 33012**] unit since [**5-11**].
Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Malignant neoplasm of other parts of bronchus or lung,Hyposmolality and/or hyponatremia,Major depressive affective disorder, single episode, severe, specified as with psychotic behavior,Other diseases of lung, not elsewhere classified,Atrial fibrillation,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Other persistent mental disorders due to conditions classified elsewhere,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy
Ac on chr diast hrt fail,Pneumonia, organism NOS,Subendo infarct, initial,Obs chr bronc w(ac) exac,Delirium d/t other cond,Mal neo bronch/lung NEC,Hyposmolality,Depr psychos-sev w psych,Other lung disease NEC,Atrial fibrillation,Chronic kidney dis NOS,Crnry athrscl natve vssl,Status-post ptca,Iatrogenc hypotnsion NEC,Adv eff coronary vasodil,Chr pulmon heart dis NEC,Mental disor NEC oth dis,DMII wo cmp nt st uncntr,Anemia in chr kidney dis,Hypothyroidism NOS,Epilep NOS w/o intr epil
Admission Date:  [**2197-5-22**]              Discharge Date:   [**2197-6-1**]

Date of Birth:  [**2117-5-12**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Pt is a 80 yo F with CAD s/precent DES to mid LCX and proximal
OM in [**3-/2197**], CRI (baseline Cr 2.1), afib not on coumadin,
multiple lung lesions on CT chest concerning for lung cancer,
DM2, and demetia who was transferred from OSH for respiratory
distress. Pt initially presented to OSH for depression as has
been at [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 33012**] unit since [**5-11**]. She was initially
started on avelox for RLL infiltrate on CXR and leukocytosis to
13. A rapid response team was called on [**5-21**] for mental status
changes, blood pressure of 90/40, HR 49, RR 20, O2 sat 79% on RA
improving to 100% with NRB. EKG showed sinus brady, no acute
ischmemic changes. BS was 248. IO was placed. Pt was acutely
agitated and required 2 mg IV haldol. She was transferred to the
ICU. During this time, she had coughed up a small amount of
stomach secretions. Antibiotics were changed to cefepime and
vancomycin. She was also given lasix 60 mg IV (previously
received IVFs for Na 122, Cr 2.9 from 2.0 on admission),
solumedrol 80 mg IV x1. She was also transfused 2 or 3 units
PRBCs for HCT 22.3 (from 31.1 on [**5-12**]) with IV lasix 20 mg. She
was having episodes of anxiety/agitation requiring haldol 2 mg
IV x2 and ativan 1 mg IV x2. ABG was 7.23/46/306.
.
At [**Hospital1 18**], pt was agitated on arrival, calmed with ativan 1 mg
x1. During episodes of agitation, pt would require NRB to keep
O2 sats in the mid-90s. Off NRB, O2 sat was in the 80s. This has
occurred 3-4 times today. Pt also required q4 nebulizers
(atrovent only). ABG was 7.37/39/65 on NRB. Pt also missed 2
doses of metoprolol, went into afib with RVR, which responded to
dilt 10 mg IV x2. SBP dipped to 90s with the dilt.
.
Pt unable to given an extensive ROS given delirium. Reported
terrible breathing. Denied CP, palpitation, nausea, abdominal
pain.

Past Medical History:
CAD (cath on [**2197-2-17**] showed 3VD, PCI to LCX and OM in [**2197-3-13**])
PAF (not anticoagulated)
CVA
Major depression with psychosis
Dementia
Hypertension
Hyperlipidemia
Hypothyroidism
DM2
CRI (baseline Cre 2.1-2.5)
Seizure disorder (unclear if ever had seizure per family)
PVD s/p femoral bypass and s/p bilateral CEA
h/o erosive gastritis on omeprazole
s/p cholecystectomy
s/p hysterectomy
Lung lesions suspicious for lung Ca
Recent strep bovis infection, colon biopsies showed adenoma.

Social History:
Former smoker (100 pk yr), quit '[**89**], rare EtOH. 3 daughters, was
living with daughter [**Name (NI) **], but more recently has been at [**First Name5 (NamePattern1) 392**]
[**Last Name (NamePattern1) 33012**] unit since [**5-11**].

Family History:
No family history of early MI, mother died at 53 yo of unknown
primary cancer. Father died in 80s.

Physical Exam:
VS T 96 HR 84 (70-90) BP 130/48 (110-150/40-60) 18 97% on 40%
face tent
Gen: obese, elderly woman in NAD
HEENT: EOMI, PERRLA, mmm
CV: irregularly irregular II/VI systolic murmur heard best at
LLSB
Resp: CTAB anteriorly no wheeze or crackles
ABd: soft, NT, + bs, non-distended
Ext: 1 + pitting edema bilat LE
Neuro: A+Ox3, will not cooperate with the rest of exam

Pertinent Results:
[**2197-5-28**] 07:05AM BLOOD WBC-13.4* RBC-3.57* Hgb-10.3* Hct-31.3*
MCV-88 MCH-29.0 MCHC-33.0 RDW-15.1 Plt Ct-315
[**2197-5-22**] 09:50AM BLOOD CK-MB-10 MB Indx-3.4 cTropnT-0.14*
[**2197-5-22**] 07:15PM BLOOD CK-MB-15* MB Indx-4.1 cTropnT-0.29*
[**2197-5-22**] 11:32PM BLOOD CK-MB-23* MB Indx-5.1 cTropnT-0.87*
proBNP->[**Numeric Identifier **]
[**2197-5-23**] 06:00AM BLOOD CK-MB-22* MB Indx-4.5 cTropnT-1.39*
[**2197-5-23**] 03:02PM BLOOD CK-MB-18* MB Indx-3.6 cTropnT-1.07*
[**2197-5-24**] 03:06AM BLOOD CK-MB-9 cTropnT-1.09*

.
EKG:
Afib, no ST changes since prior.
.
[**5-22**] cxr ap: FINDINGS: In comparison with study of [**4-28**], there
is enlargement of the cardiac silhouette with evidence of
pulmonary vascular congestion. Areas of increased opacification
at the right base and possibly behind the heart could merely
represent a combination of vascular congestion and atelectasis,
though
possible aspiration must be considered. Blunting of the right
costophrenic angle is consistent with pleural fluid.
The apparent hiatal hernia seen on the previous image is not
definitely appreciated on the current study. The nodular
opacifications seen on CT are difficult to appreciate on this
plain radiograph.
.
[**5-25**] CXR:
FINDINGS: In comparison with the study of [**5-24**], the pulmonary
vascularity has somewhat decreased. Haziness at the right base
is less prominent, though some of this may reflect a more
upright position. Enlargement of the cardiac silhouette persists
as does opacification of the left base most likely representing
pleural effusion with underlying compressive atelectasis.
.
TTE [**2197-5-26**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The ascending aorta
is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
IMPRESSION: Suboptimal image quality. Symmetric left ventricular
hypertrophy with preserved global systolic function. Pulmonary
artery systolic hypertension.

Brief Hospital Course:
80 yo woman with CAD s/p DES [**3-13**] on plavix, who was transfered
from OSH due to respiratory distress.
.
# Pneumonia: During this admission the patient was treated with
a 7-day course of antibiotics for suspected hospital acquired
pneumonia with vancomycin and zosyn with resolution of the
symptoms.
.
# NSTEMI:  Most likely secondary to demand ischemia from
increased metabolic demand of pneumonia.  The pt's troponin
peaked at 1.39 and trended down on labs on [**5-24**]. ECHO on [**5-23**]
could not rule out a focal left ventricle wall motion
abnormality. In the MICU, the pt was originally on heparin IV
for presumed NSTEMI; however, this was discontinued afted 24
hours as the pt's troponin trended down once the pt's heart rate
and hypoxia were treated. The pt never endorsed chest pain and
besides atrial fibrillation with rapid rate on telemetry during
the first 24 hours of the admission, the pt had no other
abnormalities on telemetry.  The patient was discharged on
aspirin, plavix, statin and metoprolol.
.
# Acute CHF exacerbation: Diastolic heart failure LVEF>55%. The
acute exacerbation was likely caused by NSTEMI and a fib with
RVR.  Initially the pt was admitted to the medical floor, but
was trasnfered to the ICU for treatment of her hypoxia as she
required transient bipap. The pt responded well to diuresis with
lasix 40 IV bid.  She was transitioned off BiPAP and did not
require any additional lasix once transfered to the floor.  She
will have VNA at home to monitor daily weights.
.
# COPD flare: During the pt's MICU course the pt was given
nebulizers as well as a 5-day prednisone burst that she
responded well to.  She was transitioned to a quick prednisone
taper on discharge.  She was discharged with ipratropium inhaler
and albuterol PRN.
.
# Acute MS changes:  Most likely secondary to multiple medical
problems including hypoxia on admission.  The pt's delirium
improved with remeron, treatment of the above causes of the pt's
hypoxia.  Zyprexa was used as needed for symptom management, but
not required many days prior to discharge.
.
# [**Last Name (un) **] on chronic renal failure:  Most likely caused by relative
hypotension from poor forward flow.  Improved after diuresis.
Medications, including vancomycin, were renally dosed.  Her
renal failure improved prior to discharge.
.
# Anemia: Was transfused at OSH prior to admission here;
however, HCT was stable without transfusion during admission.
Stools remained guaiac negative.  Goal Hct > 30.
.
# HTN/relative hypotension: On admission to ICU relatively
hypotensive in setting of diltiazem for a fib. Early
sepsis/cardiogenic were less likely causes however considered.
The patient's blood pressure remained stable, then gradually
became increased.  Continued metoprolol and uptitrated to 125mg
TID.  Held amlodipine, hydralazine, imdur initially then
restarted amlodipine 5mg QD.  The patient was discharged on the
increased dose of metoprolol and amlodipine alone for blood
pressure control.
.
# H/o Strep bovis bacteremia:
Bx of polyp showed adenoma, still some concern re: colon ca.
The patient will need outpatient follow up.
.
# H/o spiculated lung lesion:
Will need bronch bx (once on plavix for 3 mos) and PET scan as
outpt.
.
# Psych: Continue outpt psych meds.
.
# PPX: Heparin sub q. PPI, bowel regimen.
.
# Code: FULL
.
# HCP: [**Name (NI) **] [**Name (NI) 33007**]
.

Medications on Admission:
Metoprolol 100 mg TID
Methylphenidate 2.5 mg [**Hospital1 **]
Synthroid 75 mcg daily
Imdur 120 mg daily
hydralazine 75 mg daily
cilostazol 100 mg daily
atrovastatin 80 mg daily
Amldopine 15 mg daily
lorazepam 0.5 mg daily
Nexium 40 mg IV daily
Vancomycin 500 mg
Maxipime 1 gm
Solumedrol 80 mg IV x1
Plavix 75 mg daily
Glargine 20 units daily
citalopram 10 mg daily
ASA 81 mg daily
mirtazapine 15 mg daily
Tylenol 650 mg prn
Folic acid 1 mg daily
Nitroglycerin 0.4 mg prn
Lovenox 30 mg sq daily
Percocet 2 tablets q6 hr prn
Duoneb q4 prn
Lactulose prn

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 162 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
Disp:*1 inhaler * Refills:*2*
10. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous twice a day.
13. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day for 10 days: Please take 4 pills (40mg) tomorrow, 2 pills
(20mg) for the following four days, then 1 pill (10mg) for the
following four days, then stop.
Disp:*16 Tablet(s)* Refills:*0*
14. Albuterol 90 mcg/Actuation Aerosol Sig: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Able VNA

Discharge Diagnosis:
Primary Diagnoses:
Pneumonia
COPD exacerbation
NSTEMI
.
Secondary Diagnoses:
Paroxysmal Atrial Fibrillation
History of stroke
Major depression with psychosis
Dementia
Hypertension
Hyperlipidemia
Hypothyroidism
Type 2 Diabetes
Chronic Renal Insufficiency
Seizure disorder
Peripheral vascular disease
h/o erosive gastritis
s/p cholecystectomy
s/p hysterectomy
Lung lesions suspicious for lung Ca
Recent strep bovis infection, colon biopsies showed adenoma.


Discharge Condition:
The patient was hemodynamically stable and afebrile prior to
discharge.


Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of respiratory
distress.  You were found to have a pneumonia which you were
treated with antibiotics for.  You were also thought to have
worsening of your COPD which you were treated with steroids for.
 You also had a mild heart attack likely from the stress of the
pneumonia.
.
You should continue to weigh yourself every morning, [**Name8 (MD) 138**] MD if
weight > 3 lbs.  Adhere to 2 gm sodium diet
.
Medication Changes:
START prednisone taper:  Take 40mg for the next two days, then
20mg for 4 days, then 10mg for another 4 days, then you can stop
START Ipratropium inhaler every 6 hours
START Albuterol inhaler as needed every 6 hours for wheezing
START Folic acid 1mg daily
START Citalopram 10mg daily
START Mirtazapine 7.5mg daily
INCREASE dose of Metoprolol to 125mg three times a day
DECREASE Amlodipine 15mg to 5mg daily
DECREASE Aspirin to 162mg daily
STOP Hydralazine
STOP Imdur
STOP Cilostazol
.
Continue Lipitor 80mg daily, Plavix 75mg daily, Synthroid 75mcg
daily, Pantoprazole 40mg daily and your insulin regimen.
.
If you experience chest pain, shortness of breath, fever,
chills, bright red blood per rectum, vomiting blood, dark tarry
stools, or any other concerning symptoms please seek medical
attention.


Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 5586**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16055**] in 2 weeks.  The phone number of the office is
([**Telephone/Fax (1) 33013**].



Completed by:[**2197-6-2**]
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Malignant neoplasm of other parts of bronchus or lung,Hyposmolality and/or hyponatremia,Major depressive affective disorder, single episode, severe, specified as with psychotic behavior,Other diseases of lung, not elsewhere classified,Atrial fibrillation,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Other persistent mental disorders due to conditions classified elsewhere,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy'}


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 is a 80 yo F with CAD s/precent DES to mid LCX and proximal
OM in [**3-/2197**], CRI (baseline Cr 2.1), afib not on coumadin,
multiple lung lesions on CT chest concerning for lung cancer,
DM2, and demetia who was transferred from OSH for respiratory
distress. Pt initially presented to OSH for depression as has
been at [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 33012**] unit since [**5-11**]. She was initially
started on avelox for RLL infiltrate on CXR and leukocytosis to
13. A rapid response team was called on [**5-21**] for mental status
changes, blood pressure of 90/40, HR 49, RR 20, O2 sat 79% on RA
improving to 100% with NRB. EKG showed sinus brady, no acute
ischmemic changes. BS was 248. IO was placed. Pt was acutely
agitated and required 2 mg IV haldol. She was transferred to the
ICU. During this time, she had coughed up a small amount of
stomach secretions. Antibiotics were changed to cefepime and
vancomycin. She was also given lasix 60 mg IV (previously
received IVFs for Na 122, Cr 2.9 from 2.0 on admission),
solumedrol 80 mg IV x1. She was also transfused 2 or 3 units
PRBCs for HCT 22.3 (from 31.1 on [**5-12**]) with IV lasix 20 mg. She
was having episodes of anxiety/agitation requiring haldol 2 mg
IV x2 and ativan 1 mg IV x2. ABG was 7.23/46/306.
.
At [**Hospital1 18**], pt was agitated on arrival, calmed with ativan 1 mg
x1. During episodes of agitation, pt would require NRB to keep
O2 sats in the mid-90s. Off NRB, O2 sat was in the 80s. This has
occurred 3-4 times today. Pt also required q4 nebulizers
(atrovent only). ABG was 7.37/39/65 on NRB. Pt also missed 2
doses of metoprolol, went into afib with RVR, which responded to
dilt 10 mg IV x2. SBP dipped to 90s with the dilt.
.
Pt unable to given an extensive ROS given delirium. Reported
terrible breathing. Denied CP, palpitation, nausea, abdominal
pain.

MEDICAL HISTORY: CAD (cath on [**2197-2-17**] showed 3VD, PCI to LCX and OM in [**2197-3-13**])
PAF (not anticoagulated)
CVA
Major depression with psychosis
Dementia
Hypertension
Hyperlipidemia
Hypothyroidism
DM2
CRI (baseline Cre 2.1-2.5)
Seizure disorder (unclear if ever had seizure per family)
PVD s/p femoral bypass and s/p bilateral CEA
h/o erosive gastritis on omeprazole
s/p cholecystectomy
s/p hysterectomy
Lung lesions suspicious for lung Ca
Recent strep bovis infection, colon biopsies showed adenoma.

MEDICATION ON ADMISSION: Metoprolol 100 mg TID
Methylphenidate 2.5 mg [**Hospital1 **]
Synthroid 75 mcg daily
Imdur 120 mg daily
hydralazine 75 mg daily
cilostazol 100 mg daily
atrovastatin 80 mg daily
Amldopine 15 mg daily
lorazepam 0.5 mg daily
Nexium 40 mg IV daily
Vancomycin 500 mg
Maxipime 1 gm
Solumedrol 80 mg IV x1
Plavix 75 mg daily
Glargine 20 units daily
citalopram 10 mg daily
ASA 81 mg daily
mirtazapine 15 mg daily
Tylenol 650 mg prn
Folic acid 1 mg daily
Nitroglycerin 0.4 mg prn
Lovenox 30 mg sq daily
Percocet 2 tablets q6 hr prn
Duoneb q4 prn
Lactulose prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 96 HR 84 (70-90) BP 130/48 (110-150/40-60) 18 97% on 40%
face tent
Gen: obese, elderly woman in NAD
HEENT: EOMI, PERRLA, mmm
CV: irregularly irregular II/VI systolic murmur heard best at
LLSB
Resp: CTAB anteriorly no wheeze or crackles
ABd: soft, NT, + bs, non-distended
Ext: 1 + pitting edema bilat LE
Neuro: A+Ox3, will not cooperate with the rest of exam

FAMILY HISTORY: No family history of early MI, mother died at 53 yo of unknown
primary cancer. Father died in 80s.

SOCIAL HISTORY: Former smoker (100 pk yr), quit '[**89**], rare EtOH. 3 daughters, was
living with daughter [**Name (NI) **], but more recently has been at [**First Name5 (NamePattern1) 392**]
[**Last Name (NamePattern1) 33012**] unit since [**5-11**]. 

### Response:
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Malignant neoplasm of other parts of bronchus or lung,Hyposmolality and/or hyponatremia,Major depressive affective disorder, single episode, severe, specified as with psychotic behavior,Other diseases of lung, not elsewhere classified,Atrial fibrillation,Chronic kidney disease, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Other chronic pulmonary heart diseases,Other persistent mental disorders due to conditions classified elsewhere,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia in chronic kidney disease,Unspecified acquired hypothyroidism,Epilepsy, unspecified, without mention of intractable epilepsy'}
