CHIEF COMPLAINT: CHIEF COMPLAINT: shortness of breath
REASON FOR CCU ADMISSION: transfer for severe AS, CHF, resp.
failure

PRESENT ILLNESS: Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%),
severe AS (valve area 0.8cm2), CVA, and anemia who was admitted
to [**Hospital6 17032**] two days ago for shortness of
breath and is transferred to the [**Hospital1 18**] CCU due to CHF with
respiratory failure.

MEDICAL HISTORY: severe aortic stenosis ([**Location (un) 109**] 0.8)
HTN
CVA
depression
diverticulitis
hypothyroidism

MEDICATION ON ADMISSION: HOME MEDICATIONS:  [per transfer summary]
ASA 81mg daily
Atenolol 50mg [**Hospital1 **]
Nifedipine ER 90mg daily
Lisinopril 5mg daily
Lasix 40mg [**Hospital1 **]
Simvastatin 40mg daily
Albuterol neb Q4H PRN
Ca Carbonate 500mg [**Hospital1 **]
Calcitonin nasal spray: 1 spray daily
Maalox 30mL Q4H PRN
Sertraline 50mg daily
Lorazepam 0.25mg PO BID PRN
Tylenol 1000mg [**Hospital1 **]
Ascorbic acid 500mg [**Hospital1 **]
MTV daily
Omeprazole 20mg daily
Ferrous sulfate 325mg [**Hospital1 **]
Vitamin D 50000U weekly

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
Tcurrent: 37.8 ??????C (100.1 ??????F)
HR: 88 (88 - 115) bpm
BP: 97/45(58) {94/45(57) - 119/60(71)} mmHg
RR: 27 (19 - 32) insp/min
SpO2: 97%
FiO2 30%, PEEP 5, TV 450, RR 10
GENERAL: Elderly lady, intubated and sedated. Appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: JVP 15cm.
CARDIAC: S1 and S2; crescendo-decrescendo systolic murmur heard
best at RUSB; murmur radiates to carotids; murmur is
late-peaking with no audible A2
LUNGS: coarse breath sounds bilaterally
ABDOMEN: (+) bowel sounds; obese but nondistended; soft with no
masses
EXTREMITIES: 1+ edema to shins bilaterally
SKIN: No stasis dermatitis
NEURO: Opens eyes to voice, follows commands. PERRL. Moves
extremities spontaneously. Withdraws extremities to pain. Toes
downgoing bilaterally.
PULSES:  Carotid 2+ DP 2+ PT 2+ bilaterally

FAMILY HISTORY: no significant cardiac history

SOCIAL HISTORY: - Home: Widowed since [**2185**].  Was in rehab at [**Location (un) 25576**] prior
to presenting to the OSH.
- Tobacco history:  None
- ETOH:  None
- Illicit drugs:  None
Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Anemia, unspecified,Unspecified essential hypertension,Aortic valve disorders,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Hypercalcemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases
Acute respiratry failure,Pneumonia, organism NOS,Ac on chr diast hrt fail,Hyperosmolality,Pressure ulcer, low back,Delirium d/t other cond,Anemia NOS,Hypertension NOS,Aortic valve disorder,Hypothyroidism NOS,Depressive disorder NEC,Crnry athrscl natve vssl,Hypercalcemia,Hx TIA/stroke w/o resid,Hyperlipidemia NEC/NOS,Chr pulmon heart dis NEC
Admission Date:  [**2192-3-30**]              Discharge Date:   [**2192-4-13**]

Date of Birth:  [**2106-12-31**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
CHIEF COMPLAINT: shortness of breath
REASON FOR CCU ADMISSION: transfer for severe AS, CHF, resp.
failure

Major Surgical or Invasive Procedure:
endotracheal intubation
cardiac catheterization with no intervention


History of Present Illness:
Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%),
severe AS (valve area 0.8cm2), CVA, and anemia who was admitted
to [**Hospital6 17032**] two days ago for shortness of
breath and is transferred to the [**Hospital1 18**] CCU due to CHF with
respiratory failure.

Of note, she was admitted to the OSH twice last month due to CHF
exacerbations.  She had been doing fine at rehab until [**2192-3-28**]
when she went for a doctor's appointment and got acutely short
of breath - by the time she arrived at the OSH ED she had
decreased level of consciousness and was intubated.  She had
pulmonary edema as well as ?RLL infiltrate.  During her OSH
stay, she was ruled out for acute MI, diuresed, and treated for
CAP with Ceftriaxone and Azithromycin.  Leukocytosis reportedly
decreased from 15 on admission to 5 on the day of transfer.
Left subclavian CVL was subsequently placed and CVP was [**2-23**],
with decrease inurine output.  Given her prior aggressive
diuresis, she was given 500cc IVF followed by maintenance IVF
and 1u pRBC with improvement in her urine output.  Creatinine is
at baseline.

Also, her hospital stay has been notable for anemia.  Her
baseline Hct is 24.  Upon OSH admission her Hct was 28, but
today was 20 in the setting of the fluid boluses and she is
reportedly guaiac negative.  She is a very difficult
cross-match; did receive one unit pRBCs with repeat Hct prior to
transfer of 23.7.

On arrival to the CCU, she is intubated and sedated.  Opens eyes
to command, appears comfortable.  Per discussion with son
[**Name (NI) **], she has never had any interventions for her AS.  Has
not been complaining of chest pain.  She did have syncope in the
past (incl. syncope and a fall 1.5 years ago).  Does get short
of breath with ambulation, which has been her biggest complaint.

REVIEW OF SYSTEMS:
Patient is intubated and unable to respond.


Past Medical History:
severe aortic stenosis ([**Location (un) 109**] 0.8)
HTN
CVA
depression
diverticulitis
hypothyroidism


Social History:
- Home: Widowed since [**2185**].  Was in rehab at [**Location (un) 25576**] prior
to presenting to the OSH.
- Tobacco history:  None
- ETOH:  None
- Illicit drugs:  None

Family History:
no significant cardiac history

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Tcurrent: 37.8 ??????C (100.1 ??????F)
HR: 88 (88 - 115) bpm
BP: 97/45(58) {94/45(57) - 119/60(71)} mmHg
RR: 27 (19 - 32) insp/min
SpO2: 97%
FiO2 30%, PEEP 5, TV 450, RR 10
GENERAL: Elderly lady, intubated and sedated. Appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: JVP 15cm.
CARDIAC: S1 and S2; crescendo-decrescendo systolic murmur heard
best at RUSB; murmur radiates to carotids; murmur is
late-peaking with no audible A2
LUNGS: coarse breath sounds bilaterally
ABDOMEN: (+) bowel sounds; obese but nondistended; soft with no
masses
EXTREMITIES: 1+ edema to shins bilaterally
SKIN: No stasis dermatitis
NEURO: Opens eyes to voice, follows commands. PERRL. Moves
extremities spontaneously. Withdraws extremities to pain. Toes
downgoing bilaterally.
PULSES:  Carotid 2+ DP 2+ PT 2+ bilaterally

DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals - Tm/Tc: 98.5/98 HR: 89-93 BP: 106-115/51-54 RR:22 02
sat: 93% RA
In/Out:
Last 24H: 1040/1775 ++
Last 8H:
Weight: 75.6 kg( 75.6)

Tele: SR/ST.

FS: none

GENERAL: 85 yo F in no acute distress
HEENT: no lymphadenopathy, JVD at 14 cm
CHEST: Crackles 1/3 up bilat, no rhonchi or wheezes
CV: S1 S2 Normal in quality and intensity RRR, 3/6 systolic
murmur at LUSB.
ABD: soft, distended, BS normoactive. no rebound/guarding.
EXT: bilat ankle edema, pneumoboots in place, feet warm with
trace palp pulses.
NEURO: 3/5 strength in U/L extremities. speech clearer. Memory
impaired but trying hard to gather full picture.
SKIN: no rash, stage 2 on coccyx, covered with drsg.
PSYCH: calm, alert.

Pertinent Results:
ADMISSION LABS:
[**2192-3-30**] 05:48PM BLOOD WBC-12.6* RBC-3.41* Hgb-9.1* Hct-31.7*
MCV-93 MCH-26.7* MCHC-28.7* RDW-15.3 Plt Ct-272
[**2192-3-30**] 05:48PM BLOOD Neuts-87.3* Lymphs-7.3* Monos-1.7*
Eos-3.3 Baso-0.3
[**2192-3-30**] 05:48PM BLOOD PT-12.0 PTT-32.2 INR(PT)-1.1
[**2192-3-30**] 05:48PM BLOOD Glucose-115* UreaN-18 Creat-0.6 Na-140
K-4.2 Cl-104 HCO3-27 AnGap-13
[**2192-3-30**] 05:48PM BLOOD ALT-14 AST-22 AlkPhos-78 TotBili-0.7
[**2192-3-30**] 05:48PM BLOOD Albumin-3.4* Calcium-8.9 Phos-5.0* Mg-1.8
[**2192-3-30**] 09:04PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.026
[**2192-3-30**] 09:04PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
[**2192-3-30**] 09:04PM URINE RBC-139* WBC-5 Bacteri-FEW Yeast-NONE
Epi-0

Micro:
blood cultures ([**3-30**] and [**4-1**]): no growth
urine cultures ([**3-30**] and [**4-1**] and [**4-9**]): no growth
legionella urinary antigen ([**2192-3-30**]): negative
sputum ([**3-31**]) no growth
catheter tip from central line ([**4-1**]): no growth

STUDIES:
CXR ([**2192-3-31**]):
An ET tube is present.  The tip is partially obscured but
appears to lie
approximately 3.2 cm above the carina.  An NG tube is present,
tip extending beneath the diaphragm overlying the gastric
fundus.  A left subclavian line overlies the distal SVC,
unchanged.  No pneumothorax detected.
There is cardiomegaly.  Enlarged tapered pulmonary hilum raises
the question of pulmonary hypertension.  There is upper zone
redistribution and diffuse vascular blurring, consistent with
CHF.  There is increased retrocardiac density, consistent with
left lower lobe collapse and/or consolidation.  Probable small
bilateral effusions.   Compared with [**2192-3-30**] at 18:29 p.m.,
there has been slight interval clearing at the right lung base
and in the left mid zone, but, overall, findings are otherwise
similar.

ECHO ([**2192-3-31**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size is normal. The aortic valve leaflets are moderately
thickened. There is severe aortic valve stenosis (valve area
1.0cm2). Trace aortic regurgitation is seen. 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
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Severe aortic valve
stenosis. Mild mitral regurgitation. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Pulmonary artery hypertension.

Pathology Crossmatch ([**2192-3-30**]):
Ms [**Known lastname 1968**] has a new diagnosis of anti-E antibody. E antigen is a
member
of the Rh blood group system. Anti-E antibody is clinically
significant
and capable of causing hemolytic transfusion reactions. In the
future,
Ms [**Known lastname 1968**] should receive E antigen negative products for all red
cell
transfusions. Approximately 70% of ABO-compatible blood will be
E
antigen negative.

Limited carotid ultrasound ([**2192-4-2**])
1.  Unable to scan the right carotid artery due to presence of
central venous line.
2.  40-59% stenosis of the left internal carotid artery.

Cardiac Catheterization ([**2192-4-4**]):
FINAL DIAGNOSIS:
1. One vessel coronary artery disease of proximal LAD.
2. Moderate aortic stenosis.
3. Moderately elevated left sided filling pressure.
4. Medical rx for CAD.
5. Return to CCU.


Brief Hospital Course:
Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%),
severe AS (valve area 0.8cm2), CVA, and anemia who was admitted
to [**Hospital6 17032**] two days ago for shortness of
breath and is transferred to the [**Hospital1 18**] CCU due to respiratory
failure in the setting of CHF and PNA.

# Respiratory Failure: multifactorial. thought to be [**12-22**] aortic
stenosis as well as PNA. Pt had been started on CAP coverage at
OSH, but she has been hospitalized twice in the past month so
more appropriate to cover for HCAP. Precipitant of CHF is
unclear (was ruled out for MI, not able to answer history
questions about med/dietary compliance), but she has had
multiple hospitalizations recently for CHF. Started on
vanc/cefepime/azithro on arrival to [**Hospital1 18**] to cover for HCAP and
this was continued for 8 day course (last dose [**2192-4-7**], and
azithro for only 5d). Blood cultures neg on admission and neg
from OSH. Sputum culture had no growth. For management of CHF,
diuresed pt with lasix drip with acetazolamide as well and
removed several liters of fluid. HR consistently on 90s, so
placed pt on metoprolol rather than atenolol to get targeted HR
control and uptitrated as needed to achieve goal rate of 60-70s.
A right central line was placed in the IJ for medication
administration. Obtained echo which showed AoVA of 1.0cm^2 with
mean gradient of 30mmHg. Pt was extubated on [**2192-4-5**]. Due to
aggressive diuresis, she developed a contraction alkalosis that
inhibited her respiratory drive, so lasix drip was stopped.
Clinically and based on CXR, she was euvolemic at this point. By
day before discharge, the patient's oxygen was weaned, no longer
requiring any supplementation.
.
# CHF: As above.  Responded well to diuresis.  Switched from
atenolol to metoprolol succinate 100mg.  Also, started
lisinopril and uptitrated to 5mg on d/c. Patient is on 40mg of
torsemide per day.  The patient should have at daily weights and
ins and outs taken at the rehab facility.  Renal function and
volume status should be closely monitored.
.
# HCAP: as above, pt thought to have PNA on transfer to [**Hospital1 18**].
treated pt for HCAP due to multiple recent hospitalizations with
vanc/cefepime for 8 days and azithromycin for 5d. She became
afebrile and her WBC count normalized.  She continued to have
excessive secretions.  Treated with chest PT, nebulizers,
guaifenison.

# severe AS: pt has normal EF on echo but severe AS, mild LVH,
and pulm artery HTN. likely severe AS has caused her recent
multiple hosp admissions for acute CHF. managed volume status as
above in resp failure. managed HR with uptitration of metoprolol
succinate to 100mg qd. Spoke with outpatient cardiologist Dr.
[**Last Name (STitle) **] [**Name (STitle) 13469**] re: AS work up. Pt had never had significant work
up for AS because she had never been symptomatic other than mild
chest pressure on exertion. Valve area=0.9, peak=33, mean=20 in
[**2190**]. He thought was good percutaneous candidate due to
underlying history of lung disease. Consulted c-[**Doctor First Name **] to eval for
op candidacy and obtained testing as requesting:  carotid US
(result: Unable to scan the right carotid artery due to presence
of central venous line. 40-59% stenosis of the left internal
carotid artery), MSSA swab (positive), and cardiac cath (result:
AS moderate, wedge 14-15, CI 2.3, 60-70% proximal LAD lesion).
Given AS only moderate, is not currently a surgical candidate.

# Altered mental status:  At baseline, per family, patient is
functional, conversational and able to perform ADLs.  After
extubation, patient was confused, not speaking, inconsistently
following commands.  This was thought to be secondary to
electrolyte disturbances (hyperNa and hyperCa).  She was treated
with free water boluses as well as calcitonin salmon for
hyperCa.  Her mental status improved significantly by the time
of discharge, to approximately 85% of baseline, per son.

# Nutrition:  Patient failed speech and swallow evaluation
initially.  Thus, NG tube was placed and tube feeds were
initiated.  The tube feed and NG tube was removed on [**4-12**], and
the patient was able to take PO meds and food by time of
discharge.  Repeat speech and swallow evaluation was as follows
recommendations:  1. Continue PO diet of thin liquids and puree.
2. Pills crushed with puree. Small pills may be whole with
puree. 3. 1:1 assist for all POs.

# HTN: BP was stable off home meds. Held lisinopril and
nifedipine in setting of normotension. continued BB but switched
home atenolol to metoprolol for better rate control.

# Anemia, acute on chronic: Pt has a h/o anemia (Hct 28) and was
stable on arrival to the OSH, but had a precipitous drop the day
of transfer to Hct 20. Hct bumped appropriately with 1u pRBCs to
Hct 23 at OSH. Etiology thought to be most likely hemodilution
in the setting of IVF's initially. No evidence of bleeding.
Hemolysis labs neg. Stool guaiac neg. DIC labs neg. iron studies
c/w anemia of chronic disease. This was likely [**12-22**] acute PNA and
worsening of CHF.

INACTIVE ISSUES

#  h/o CVA: no obvious deficit.  continued ASA and statin
#  HLD: stable. continued Simvastatin
#. Hypothyroidism: stable. continued Levothyroxine
#. Depression: stable. continued Sertraline

TRANSITIONAL ISSUES:
- f/u with PCP s/p discharge from rehab
- f/u with cardiologist in [**11-21**] weeks
- f/u daily weights and track volume status, adjust torsemide as
needed

Medications on Admission:
HOME MEDICATIONS:  [per transfer summary]
ASA 81mg daily
Atenolol 50mg [**Hospital1 **]
Nifedipine ER 90mg daily
Lisinopril 5mg daily
Lasix 40mg [**Hospital1 **]
Simvastatin 40mg daily
Albuterol neb Q4H PRN
Ca Carbonate 500mg [**Hospital1 **]
Calcitonin nasal spray: 1 spray daily
Maalox 30mL Q4H PRN
Sertraline 50mg daily
Lorazepam 0.25mg PO BID PRN
Tylenol 1000mg [**Hospital1 **]
Ascorbic acid 500mg [**Hospital1 **]
MTV daily
Omeprazole 20mg daily
Ferrous sulfate 325mg [**Hospital1 **]
Vitamin D 50000U weekly


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
2. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/wheeze.
7. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) spray Nasal once a day.
8. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO twice a
day.
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): give at same time as iron.
11. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
12. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
14. Vitamin D3 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
15. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal rashincluding under
breasts.
16. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
Acute on chronic diastolic congestive heart failure
Pneumonia
Moderate Aortic Stenosis
Hypertension
Anemia
Left pleural effusion
Hypernatremia
Delerium


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mrs. [**Known lastname 1968**],

It was a pleasure taking care of you.  You were admitted to the
[**Hospital1 69**] for an exacerbation of your
heart failure and pneumonia.
.
Weigh yourself every morning before breakfast, call Dr. [**Last Name (STitle) 11493**] if
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.

We made the following changes to your medicines:
1. Discontinue Atenolol, furosemide, nifedipine, Maalox,
lorazepam and omeprazole
2. Start taking metoprolol xl to lower your heart rate
3. START taking torsemide to get rid of extra fluid
4. Start using miconazole for the rash under your breasts.

Followup Instructions:
Name:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] [**Name8 (MD) 11493**], MD
Specialty: Cardiology
Address: [**Apartment Address(1) 28703**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 11650**]
When: [**Last Name (LF) 2974**], [**4-27**] at 2:00pm
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Anemia, unspecified,Unspecified essential hypertension,Aortic valve disorders,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Hypercalcemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases'}


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: CHIEF COMPLAINT: shortness of breath
REASON FOR CCU ADMISSION: transfer for severe AS, CHF, resp.
failure

PRESENT ILLNESS: Ms. [**Known lastname 1968**] is an 85y/o lady with HTN, diastolic HF (EF 70%),
severe AS (valve area 0.8cm2), CVA, and anemia who was admitted
to [**Hospital6 17032**] two days ago for shortness of
breath and is transferred to the [**Hospital1 18**] CCU due to CHF with
respiratory failure.

MEDICAL HISTORY: severe aortic stenosis ([**Location (un) 109**] 0.8)
HTN
CVA
depression
diverticulitis
hypothyroidism

MEDICATION ON ADMISSION: HOME MEDICATIONS:  [per transfer summary]
ASA 81mg daily
Atenolol 50mg [**Hospital1 **]
Nifedipine ER 90mg daily
Lisinopril 5mg daily
Lasix 40mg [**Hospital1 **]
Simvastatin 40mg daily
Albuterol neb Q4H PRN
Ca Carbonate 500mg [**Hospital1 **]
Calcitonin nasal spray: 1 spray daily
Maalox 30mL Q4H PRN
Sertraline 50mg daily
Lorazepam 0.25mg PO BID PRN
Tylenol 1000mg [**Hospital1 **]
Ascorbic acid 500mg [**Hospital1 **]
MTV daily
Omeprazole 20mg daily
Ferrous sulfate 325mg [**Hospital1 **]
Vitamin D 50000U weekly

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
Tcurrent: 37.8 ??????C (100.1 ??????F)
HR: 88 (88 - 115) bpm
BP: 97/45(58) {94/45(57) - 119/60(71)} mmHg
RR: 27 (19 - 32) insp/min
SpO2: 97%
FiO2 30%, PEEP 5, TV 450, RR 10
GENERAL: Elderly lady, intubated and sedated. Appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: JVP 15cm.
CARDIAC: S1 and S2; crescendo-decrescendo systolic murmur heard
best at RUSB; murmur radiates to carotids; murmur is
late-peaking with no audible A2
LUNGS: coarse breath sounds bilaterally
ABDOMEN: (+) bowel sounds; obese but nondistended; soft with no
masses
EXTREMITIES: 1+ edema to shins bilaterally
SKIN: No stasis dermatitis
NEURO: Opens eyes to voice, follows commands. PERRL. Moves
extremities spontaneously. Withdraws extremities to pain. Toes
downgoing bilaterally.
PULSES:  Carotid 2+ DP 2+ PT 2+ bilaterally

FAMILY HISTORY: no significant cardiac history

SOCIAL HISTORY: - Home: Widowed since [**2185**].  Was in rehab at [**Location (un) 25576**] prior
to presenting to the OSH.
- Tobacco history:  None
- ETOH:  None
- Illicit drugs:  None 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Pressure ulcer, lower back,Delirium due to conditions classified elsewhere,Anemia, unspecified,Unspecified essential hypertension,Aortic valve disorders,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Hypercalcemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Other chronic pulmonary heart diseases'}
