CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: 77 yo woman with CAD s/p stent and restented in [**2163**] and [**2170**],
IDDM, HTN, HLD, h/o renal transplant who presents with DOE, SOB,
tachypnea for today. States she has had no weight gain Otherwise
ROS negative except for general fatigue.  Denies dietary
indiscretion and states she has been taking all of her
medications as prescribed.
.
In the ED, initial vitals were P 57, 110/29, R 18, O2 100% on
2L. She was hypoxic 86% RA, improved with nebX3 to 90-92% RA.
Lung exam was bilateral wet-sounding rales [**1-22**] way up. No
significant lower extremity edema. Speaking in full sentenses.
CXR looked like fluid overload. BNP was increased from prior, CK
elevated but MBI and trop negative. K 5.9, received nebs, ASA
325, calcium gluconate 1G, 1 amp D50, 1amp bicarb, kayexalate
30G PO insulin 10U. Hct 29 (baseline). Renal function worse (Cr
now 4.2), lasix 40mg IV X1..
.
EKG slightly peaked T's.
.
Patient recently admited for CHF exacerbation.  She was d/c'd on
oxgen 1-2L which she has been using. She recently missed her
appointment with Dr. [**Last Name (STitle) **] for PFTs and f/u of ground glass
opacities and bronchial dilation.
.
VS on transfer to the floor, 52, 132/43, 17, 100% 3L.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes (poorly controlled on
insulin (reports takes BS 3x per day, often high 100s to 200),
+Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:  PCI--[**2163**] stenting of the
RCA, restented in [**2170**]
-PACING/ICD:
.
Non-cardiac:
-recent admission in early [**Month (only) 321**] for resp failure, CHF
exacerbation complicated by NSTEMI and transplant pyelonephritis

MEDICATION ON ADMISSION: per dc summary from [**2173-12-5**]- patient does not recall
1.Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2.Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3.Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6.Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7.Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8.NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day.
9.Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous twice a day: to be taken with breakfast and
dinner.
10.Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11.Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
12.Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13.Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Iodine; Iodine Containing / Lisinopril

PHYSICAL EXAM: baseline wt 152 lbs per Dr[**Name (NI) 9388**] note from [**12-29**]; pt states
she has been 150 at home.  Is 156 here on our scale.
VS:  97.7, 59, 124/52, 98%/4L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. pupils constricted, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Dry MM.
NECK: supple, no elevated JVP
CARDIAC: RR, normal S1, S2. III/VI MR murmur. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB except
crackles at bases b/l L>R.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No calf TTP.
Pulses: 2+ DPs b/l

FAMILY HISTORY: Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN

SOCIAL HISTORY: Widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able
Acute on chronic diastolic heart failure,Acute kidney failure with other specified pathological lesion in kidney,End stage renal disease,Hemoperitoneum (nontraumatic),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney replaced by transplant,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Aftercare following organ transplant,Subendocardial infarction, subsequent episode of care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other iatrogenic hypotension,Mitral valve disorders,Other specified disorders resulting from impaired renal function,Other nonspecific findings on examination of blood,Other chronic pulmonary heart diseases,Other dependence on machines, supplemental oxygen,Personal history of tobacco use
Ac on chr diast hrt fail,Acute kidney failure NEC,End stage renal disease,Hemoperitoneum,Hyp kid NOS w cr kid V,Kidney transplant status,Hemorrhage complic proc,Ac posthemorrhag anemia,Aftercare organ transplt,Subendo infarct, subseq,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hyperpotassemia,DMII wo cmp nt st uncntr,Long-term use of insulin,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Abn react-procedure NEC,Iatrogenc hypotnsion NEC,Mitral valve disorder,Impair ren funct dis NEC,Oth nspcf finding blood,Chr pulmon heart dis NEC,Depend-supplement oxygen,History of tobacco use
Admission Date:  [**2174-1-18**]              Discharge Date:   [**2174-1-28**]

Date of Birth:  [**2096-7-19**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Iodine; Iodine Containing / Lisinopril

Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
Renal biopsy complicated by hemoperitoneum
Right internal jugular central line placement


History of Present Illness:
77 yo woman with CAD s/p stent and restented in [**2163**] and [**2170**],
IDDM, HTN, HLD, h/o renal transplant who presents with DOE, SOB,
tachypnea for today. States she has had no weight gain Otherwise
ROS negative except for general fatigue.  Denies dietary
indiscretion and states she has been taking all of her
medications as prescribed.
.
In the ED, initial vitals were P 57, 110/29, R 18, O2 100% on
2L. She was hypoxic 86% RA, improved with nebX3 to 90-92% RA.
Lung exam was bilateral wet-sounding rales [**1-22**] way up. No
significant lower extremity edema. Speaking in full sentenses.
CXR looked like fluid overload. BNP was increased from prior, CK
elevated but MBI and trop negative. K 5.9, received nebs, ASA
325, calcium gluconate 1G, 1 amp D50, 1amp bicarb, kayexalate
30G PO insulin 10U. Hct 29 (baseline). Renal function worse (Cr
now 4.2), lasix 40mg IV X1..
.
EKG slightly peaked T's.
.
Patient recently admited for CHF exacerbation.  She was d/c'd on
oxgen 1-2L which she has been using. She recently missed her
appointment with Dr. [**Last Name (STitle) **] for PFTs and f/u of ground glass
opacities and bronchial dilation.
.
VS on transfer to the floor, 52, 132/43, 17, 100% 3L.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes (poorly controlled on
insulin (reports takes BS 3x per day, often high 100s to 200),
+Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:  PCI--[**2163**] stenting of the
RCA, restented in [**2170**]
-PACING/ICD:
.
Non-cardiac:
-recent admission in early [**Month (only) 321**] for resp failure, CHF
exacerbation complicated by NSTEMI and transplant pyelonephritis

- ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in
[**3-26**]. (baseline Cr 2.0)
-last bx [**12-27**]- high proportion of glomeruli sclerosed
-hemodialysis for 1.5 yrs prior to txplant
-Hypothyroidism


Social History:
Widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able

to exercise with 15-20 minutes walking daily.
Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day
ETOH- None
Illicits- None


Family History:
Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN


Physical Exam:
baseline wt 152 lbs per Dr[**Name (NI) 9388**] note from [**12-29**]; pt states
she has been 150 at home.  Is 156 here on our scale.
VS:  97.7, 59, 124/52, 98%/4L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. pupils constricted, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Dry MM.
NECK: supple, no elevated JVP
CARDIAC: RR, normal S1, S2. III/VI MR murmur. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB except
crackles at bases b/l L>R.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No calf TTP.
Pulses: 2+ DPs b/l


Pertinent Results:
at admission:
9.0>29<278
N 83.5, L10.5, M4.1, E1.5, B0.3
.
136 | 100 | 94
----------------103
5.9 | 21 | 4.2
baseline Cr 1.5 -3, had been trending up since discharge
.
repeat:
135/4.9/96/27/90/4.4<pend
.
proBNP: 7531
.
CK 900 down to 630 then 404
MB index 1.9-2.0, Trop <.01 X3
.
Tac level [**1-19**] <2
ALT 18, AST 38, AlkPhos 34, TB 0.4
.
UA neg for UTI
.
[**9-29**]
Chol 167, LDL 100, HDL 29, TG 190
.
EKG:  SR @70, NL axis approx 0 degress, NL intervals, peaked T
waves present previously but mildly increased in anterior leads
.
CXR [**1-18**]: Since examination of [**2173-11-29**], there has been interval
improvement in moderate pulmonary interstitial edema, though
mild interstitial pulmonary edema persists, as manifested by
prominence of the interstitial markings and redistribution of
the pulmonary vasculature. Trace left pleural effusion.
.
2D-ECHOCARDIOGRAM:  [**11-29**]
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2172-8-14**], no major change is evident.
.
CARDIAC CATH:  [**6-26**]
1. Selective coronary angiography of this right dominant system
demonstrated two vessel CAD. The LMCA was calcified but without
significant disease. The LAD ahd diffuse disease, especially in
teh mid segment up to 70%. The LCX had mild diffuse disease. The
RCA had a 90% hazy lesion in the mid vessel which was diffusely
diseased and
calcified. The distal vessel had 50-60% ISR.
2. Limited hemodynamics demonstrated minimally elevated left
sided
filling pressures with LVEDP=13 mmHg.
3. Left ventriculography was deferred.
4. Successful placement of two overlapping Vision bare metal
stents in proximal RCA with considerable difficulty and effort
(3.0 x 12 mm
distally and 3.0 x 8 mm proximally). Final angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Mild left ventricular diastolic dysfunction.
3. Successful placement of two bare metal stents in proximal
RCA.

TTE [**2174-1-19**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is dilated with
depressed free wall contractility. The aortic valve leaflets are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. At least mild to moderate ([**1-22**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.

Compared with the prior study (images reviewed) of [**2173-11-23**],
mitral regurgitation is now more prominent, the right ventricle
is now larger and estimated pulmonary artery systolic pressure
is now higher.

CXR [**2174-1-18**]
FINDINGS: Since examination of [**2173-11-29**], there has been interval
improvement in moderate pulmonary interstitial edema, though
mild interstitial pulmonary edema persists, as manifested by
prominence of the interstitial markings and redistribution of
the pulmonary vasculature. Trace left pleural effusion. No
evidence of pneumothorax. Stable appearance of cardiomediastinal
silhouette demonstrates moderate cardiomegaly, atherosclerotic
calcification and tortuosity of the thoracic aorta. Multilevel
degenerative change of the thoracolumbar spine is noted with
marginal osteophytic formation.
  IMPRESSION:
Mild interstitial pulmonary edema, improved since [**2173-11-29**].

Renal U/S [**2174-1-20**]
FINDINGS: The renal transplant is visualized in the right lower
quadrant, and measures 11.4 cm longitudinally. The renal cortex
is well preserved, with relatively good corticomedullary
differentiation. Two nonobstructing calculi are again seen in
the upper pole and interpolar region as before and are
unchanged. There is no associated hydronephrosis.
  On color Doppler, there is adequate perfusion of the renal
transplant.
  Again the resistive indices are increased, however, more so
than on the
previous ultrasound. The resistive indices vary from 0.87 to
0.92 within the kidneys. The peak systolic velocity in the main
renal artery is 135 cm/sec.  Again diastolic flow is almost
absent as before.
  Views of the urinary bladder show a urinary catheter within
the urinary
bladder, which is empty.
  There are no perinephric collections.
CONCLUSION:
1. Further increase in resistive indices, possibly due to
rejection.
2. Two nonobstructing renal calculi as before.
.
Renal biopsy PATHOLOGY:
1.  There is no evidence of acute cellular or humoral rejection
in this sample.
2.  The differential diagnosis includes obstruction, drug
nephrotoxicity, and especially "acute tubular necrosis".
3.  Cortical sample size is limited.

Brief Hospital Course:
77 yo woman with CAD s/p stent and restent in [**2163**] and [**2170**],
IDDM, HTN, HLD, h/o renal transplant who presents with DOE.
.
# Dyspnea/acute on chronic diastolic CHF: With mild elevation in
weight here, no associated symptoms, and elevated BNP, as well
as CXR findings, concerning for acute on chronic diastolic CHF
exacerbation.  In the setting of worsened forward flow this
would account for both dyspnea and acute on chronic renal
failure.  Differential also includes infectious, however WBC not
significantly increased and patient remained afebrile.  With
immunosuppression, and recent CT lung findings of ground glass,
concerning for opportunistic infection or lymphoproliferative
d/o causing a primary pulmonary process.  UA was significant for
no infection.  CXR did not show a pneumonia. PE also on the
differential, however patient would not currently tolerate a CTA
given her renal failure and have other more likely reasons for
dyspnea. Ischemia in the differential, however CEs not elevated
and EKG unchanged and patient without CP.  Patient did not
respond appropriately to IV Lasix so a Lasix drip was started on
[**1-20**].  A TTE showed worsened mitral regurgitation. Patient
eventually diuresed sufficiently with the lasix drip and
metolazone with a 5 kg weight loss, although she maintained a
~2L oxygen requirement (up from baseline of 1-2L oxygen at home.
Patient also continued to have persistent bibasilar crackles,
although gradually improved throughout her hospital course.
Patient underwent renal biopsy that was complicated by
hemoperitoneum. Although she became volume up as a result of her
transfusions for the hemoperitoneum, she appeared to be
autodiuresing during her MICU stay. Upon transfer to the floor,
patient was diuresed with home PO Lasix 80mg with good effect.
It was ultimately decided by the renal transplant team to
continue patient on home Lasix upon discharge and Metolazone
2.5mg daily as needed (if weight gain exceeds 2 pounds daily
when checked in the mornings post-void). These instructions were
clearly conveyed to patient and family (sister/nephew) upon
discharge.
.
# Anemia: Possibly due to renal failure.  Iron, B12 and folate
studies were significant for elevated ferritin, as likely acute
phase reactant. All other values were within normal limits
(iron, TIBC, B12, folate etc.) She required 1U of PRBC on [**1-20**].
 LFTs normal.  [**Month (only) 116**] consider outpatient EPO. Patient developed
hemoperitoneum during renal biopsy, associated with hypotension
and Hct drop from 33.6 to 27.7. Patient required 4 units of
pRBCs, 2 units platelets, 2 units of cryoprecipitate. By
[**2174-1-25**], patient's Hct had stabilized to her baseline anemia.
Patient was started on ferrous sulfate.
.
# [**Last Name (un) **] sp renal transplant: Cr elevated to 4.4 from baseline 1.6,
likely due to poor forward flow as FEurea inconclusive and no
casts in urine sediment.  Patient was followed by the renal
transplant service.  [**Last Name (un) **] was held, upon discharge as well.
Renal transplant followed. MMF and prograf were continued; Tac
level was low on day after admission but became therapeutic by
the day of discharge. Daily tacrolimus levels never exceeded
therapeutic level for any concerns of renal toxicity. Bactrim
was continued for prophylaxis.  Urine sediment did not have
evidence of ATN. Transplant kidney ultrasound on [**1-20**] showed
possible rejection so patient underwent a biopsy of her kidney
graft on [**2173-1-24**] for evaluation of her acute on chronic renal
failure that was complicated by hemoperitoneum, hypotension, and
hct drop from 33.6 to 27.7.  She was ultimately transfused 4
units of PRBCs, 2 units platelets, 2 units of cryoprecipitate.
Her hematocrit eventually stabilized.  Transplant surgery and
nephrology followed her during this portion of her
hospitalization. Patient's renal biopsy pathology ultimately was
negative for acute cellular or humoral rejection. With gentle
diuresis and discontinued [**Last Name (un) **], patient's creatinine trended down
to 2.6. Patient did have some abdominal pain during the latter
portion of her hospitalization, felt likely due to the
hemoperitoneum. She was initially treated with IV Morphine, then
Dilaudid PO and eventually Tylenol PRN with good effect. Her
diet after the hemoperitoneum was started at clears and
gradually advanced without complications. Patient was also
briefly treated with cipro/vanc/flagyl while in the MICU and on
the first day back on the floor for the hemoperitoneum.
.
#. AG metabolic acidosis:  Most likely due to ARF and resolved
quickly after admission.
.
#. Hyperkalemia:  Resolved after ED intervention.  [**Month (only) 116**] consider
restarting [**Last Name (un) **] in future with close monitoring. Held [**Last Name (un) **] during
this admission and upon discharge given patient's hyperkalemia
and acute on chronic renal insufficiency.
.
# Elevated CK: Ddx includes myositis versus mild rhabdo, ACS but
unlikely as MB index normal and no increase in troponin. Started
to downtrend immediately at admission.  Unclear etiology.
.
# HTN: Goal SBP 130.  Patient had BPs more in the 100-120 range.
 Amlodipine was continued and Valsartan was held. After
patient's hemoperitoneum, all blood pressure medications were
held. Once her blood pressure (SBP150-160s) and hematocrit
stabilized, patient was gradually resumed on her blood pressure
medications, starting with Metoprolol and then Amlodipine.
Valsartan was held upon discharge per above.
.
#  DM: Placed on Insulin S/S during her hospitalization. Patient
was encouraged to resume her home insulin sliding scale and
fixed doses of glargine and NPH upon discharge. She is followed
at the [**Last Name (un) **] Diabetes Center.
.
#  Hypothyroidism: most recent TSH: 1.1 in [**11-29**] so continued
Levothyroxine
.
# HLD: Continued Atorvastatin and Tricor as no sxs of
rhabdomylysis.
.
# CODE: Full (documented from previous and confirmed with
Filipino interpreter over the phone)
.
Patient was discharged with home oxygen and physical therapy
# Contact: sister: [**Name (NI) 105179**] [**Name (NI) 105180**] [**Telephone/Fax (1) 105181**]

Medications on Admission:
 per dc summary from [**2173-12-5**]- patient does not recall
1.Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2.Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3.Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6.Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7.Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8.NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day.
9.Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous twice a day: to be taken with breakfast and
dinner.
10.Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11.Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
12.Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13.Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

Disp:*30 Tablet(s)* Refills:*2*
14.Oxygen
1L/min continuous flow portable oxygen to maintain O2 sat
greater than 92%; Room air sat 84% during inpatient stay
Diagnosis: diastolic heart failure
15.Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
.
ALLERGIES: penicillin (denies), iodine, lisinopril

Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO HS (at bedtime): take 1 pill after dinner for 2 weeks
then increase to 1 pill twice a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for weight gain >2 pounds : ONLY TAKE AS NEEDED: When
your daily weight, checked in the morning, is 2 pounds heavier
than the day before(weigh yourself only after you have urinated
in the morning).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
12. Insulin
Please resume your home insulin sliding scale, glargine and NPH
13. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
14. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
15. Home Oxygen
1L/min continuous flow portable oxygen to maintain O2 sat
greater than 92%


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary:
- Acute on chronic diastolic CHF
- Acute on chronic renal failure
.
Secondary:
- Insulin dependent diabetes mellitus
- Hyperlipidemia
- Hypertension


Discharge Condition:
Mental Status: alert and oriented X3
Ambulating well without assistance


Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of shortness of breath.  You had more fluid on your body
than usual because of your heart failure.  You were on a
continuous dose of a medication called Lasix to help take off
the fluid.  Your weight at discharge was 147.6 pounds.
.
Your creatinine was also increased during this admission.  You
had an ultrasound of your kidney which was concerning for
rejection of your transplant. Renal biopsy samples, however,
showed NO acute rejection of your kidney transplant. Your kidney
function gradually removed. Unfortunately, you bled internally
after the biopsy procedure.  You received blood transfusions and
the bleeding eventually stopped.  You were followed by your
nephrologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**] during this hospitalization.
.
CONTINUE to take these medications:
Cellcept 1000mg twice a day
Bactrim once a day
Metoprolol SR 100mg once a day
Aspirin 81 mg once a day
Lasix 80mg once a day
Tricor 145 mg once a day
Levothyroxine 88mcg daily
Prograf 3 capsules twice a day
Atorvastatin 20mg daily
Amlodipine 10mg daily
.
CHANGE this medication:
INSTEAD OF Metolazone 2.5 mg daily, ONLY TAKE Metolazone 2.5mg
daily AS NEEDED: When your daily weight, checked in the morning,
is 2 pounds heavier than the day prior (weigh yourself only
after you have urinated in the morning)
.
RESUME your home insulin sliding scale, glargine and NPH
.
STOP taking this medication:
Valsartan
.
Also START taking this medication:
Ferrous Sulfate 325 mg (iron) after dinner.  Take one pill for 2
weeks.  Then take 1 pill twice a day.  Be sure to take Colace
with this medication since it can cause constipation.

Followup Instructions:
You have the following appointments:
Your primary care doctor, Dr. [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D.
Date/Time:[**2174-2-3**] 11:40
.
Your kidney doctor (nephrologist), Dr. [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D.
Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2174-2-3**] 2:00
.
Your eye doctor (opthalmologist), Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D.
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-3-9**] 9:30


                             [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
{'Acute on chronic diastolic heart failure,Acute kidney failure with other specified pathological lesion in kidney,End stage renal disease,Hemoperitoneum (nontraumatic),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney replaced by transplant,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Aftercare following organ transplant,Subendocardial infarction, subsequent episode of care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other iatrogenic hypotension,Mitral valve disorders,Other specified disorders resulting from impaired renal function,Other nonspecific findings on examination of blood,Other chronic pulmonary heart diseases,Other dependence on machines, supplemental oxygen,Personal history of tobacco 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: Dyspnea on exertion

PRESENT ILLNESS: 77 yo woman with CAD s/p stent and restented in [**2163**] and [**2170**],
IDDM, HTN, HLD, h/o renal transplant who presents with DOE, SOB,
tachypnea for today. States she has had no weight gain Otherwise
ROS negative except for general fatigue.  Denies dietary
indiscretion and states she has been taking all of her
medications as prescribed.
.
In the ED, initial vitals were P 57, 110/29, R 18, O2 100% on
2L. She was hypoxic 86% RA, improved with nebX3 to 90-92% RA.
Lung exam was bilateral wet-sounding rales [**1-22**] way up. No
significant lower extremity edema. Speaking in full sentenses.
CXR looked like fluid overload. BNP was increased from prior, CK
elevated but MBI and trop negative. K 5.9, received nebs, ASA
325, calcium gluconate 1G, 1 amp D50, 1amp bicarb, kayexalate
30G PO insulin 10U. Hct 29 (baseline). Renal function worse (Cr
now 4.2), lasix 40mg IV X1..
.
EKG slightly peaked T's.
.
Patient recently admited for CHF exacerbation.  She was d/c'd on
oxgen 1-2L which she has been using. She recently missed her
appointment with Dr. [**Last Name (STitle) **] for PFTs and f/u of ground glass
opacities and bronchial dilation.
.
VS on transfer to the floor, 52, 132/43, 17, 100% 3L.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes (poorly controlled on
insulin (reports takes BS 3x per day, often high 100s to 200),
+Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:  PCI--[**2163**] stenting of the
RCA, restented in [**2170**]
-PACING/ICD:
.
Non-cardiac:
-recent admission in early [**Month (only) 321**] for resp failure, CHF
exacerbation complicated by NSTEMI and transplant pyelonephritis

MEDICATION ON ADMISSION: per dc summary from [**2173-12-5**]- patient does not recall
1.Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2.Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3.Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4.Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5.Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6.Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7.Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8.NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day.
9.Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous twice a day: to be taken with breakfast and
dinner.
10.Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11.Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
12.Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13.Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Iodine; Iodine Containing / Lisinopril

PHYSICAL EXAM: baseline wt 152 lbs per Dr[**Name (NI) 9388**] note from [**12-29**]; pt states
she has been 150 at home.  Is 156 here on our scale.
VS:  97.7, 59, 124/52, 98%/4L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. pupils constricted, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Dry MM.
NECK: supple, no elevated JVP
CARDIAC: RR, normal S1, S2. III/VI MR murmur. No thrills, lifts.
No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB except
crackles at bases b/l L>R.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No calf TTP.
Pulses: 2+ DPs b/l

FAMILY HISTORY: Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN

SOCIAL HISTORY: Widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able 

### Response:
{'Acute on chronic diastolic heart failure,Acute kidney failure with other specified pathological lesion in kidney,End stage renal disease,Hemoperitoneum (nontraumatic),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Kidney replaced by transplant,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Aftercare following organ transplant,Subendocardial infarction, subsequent episode of care,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other iatrogenic hypotension,Mitral valve disorders,Other specified disorders resulting from impaired renal function,Other nonspecific findings on examination of blood,Other chronic pulmonary heart diseases,Other dependence on machines, supplemental oxygen,Personal history of tobacco use'}
