CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 75 F with CAD s/p to stent to RCA [**2116**], COPD recently started on
home oxygen, HTN, PVD who inititally presented to [**Hospital 1474**]
Hospital after for ongoing SOB since the beginning of [**Month (only) 404**].
Pt states that since early [**Month (only) 404**], she has been experiencing
worsening shortness of breath that has occurred on exercise & at
rest.  She has been unable to sleep or tolerate recumbency.  She
has had an ongoing cough productive of clear-white sputum
without hemoptysis.  She experienced one episode of chest
thightness/sharp chest pain roughly 3 weeks ago.  This pain was
non-radiation; it was not associated with diaphoresis, nausea,
vomiting.
.
She was seen by her PCP and started on inhalers for concern
regarding possible URI. On Monday, she was started on
azithromycin yesterday as well as home oxygen with a plan to
increase her prednisone.
.
Early on the morning of admission, she had worsening SOB/DOE so
she called 911 & was brought to [**Hospital 1474**] Hospital.  There was
iniital concern for a COPD exacerbation; she was given 250 mg
azithro, 1 gm cftx, albuterol/ipratropium nebs, IV solumedrol
125 mg IV. CXR showed bilateral effusions. CTA was negative for
PE.
.
Pt ruled in for NSTEMI (trop 2.76 -> 4.02).  She was given 325
mg ASA, plavix 75 mg, & she was started on heparin gtt.  She was
also given 40 mg IV lasix and subsequently transferred to [**Hospital1 18**]
for possible cath.
.
REVIEW OF SYSTEMS: As per HPI. No headache, dizziness, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, myalgias, or arthralgias. No history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery. No recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
PND, ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: -Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis

MEDICATION ON ADMISSION: Aspirin 81mg daily
Celebrex 100mg daily
Simvastatin 20mg nightly
Prednisone 5 mg daily
Metoprolol 25mg daily
Omeprazole 20mg daily
Amlodipine 5mg daily
Vitamin D 400 units daily
Calcium carbonate - 6 tabs daily
Keppra 1500mg [**Hospital1 **]
B12 injection once per month
Timolol 0.5% one drop to each eye daily in AM (not recently
taking)
Brimodidine 0.15% one drop left eye [**Hospital1 **] (not recently taking)
Optive dry eye solution, both eyes TID (not recently taking)

ALLERGIES: Tape [**12-14**]"X10YD / Morphine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T= 95.6 BP= 135/69 HR= 105 RR= 18 O2 sat= 95% RA
GENERAL: thin elderly female, resting comfortably but fatigued
appearing, NAD
HEENT: NCAT. Sclera anicteric. Pupils equal, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. Slightly dry mucous membranes/
NECK: Supple with JVD to mandible.
CARDIAC: RRR, normal S1, S2. No m/r/g. Distant heart sounds.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds with bibasilar crackles, no wheezing or rhonchi.
ABDOMEN: Bowel sounds present, soft, non-tender, non-distended,
no organomegaly, no guarding or rebound tenderness.
EXTREMITIES: Warm, DPs 2+ bilaterally, no edema
SKIN: No stasis dermatitis or other rashes.
NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 throughout,
sensation grossly intact to light touch
PSYCH: Calm, appropriate

FAMILY HISTORY: No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

SOCIAL HISTORY: - Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.
Other complications due to other cardiac device, implant, and graft,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Hematoma complicating a procedure,Oliguria and anuria,Other iatrogenic hypotension,Other emphysema,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities with intermittent claudication,Percutaneous transluminal coronary angioplasty status,Macular degeneration (senile), unspecified,Rheumatoid arthritis,Hypoxemia,Pernicious anemia,Disorder of bone and cartilage, unspecified,Unspecified glaucoma,Do not resuscitate status,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Other acquired absence of organ,Personal history of tobacco use,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other diuretics causing adverse effects in therapeutic use
Comp-oth cardiac device,Ac on chr syst hrt fail,Subendo infarct, initial,Hematoma complic proc,Oliguria & anuria,Iatrogenc hypotnsion NEC,Emphysema NEC,Epilep NOS w/o intr epil,Crnry athrscl natve vssl,Ath ext ntv at w claudct,Status-post ptca,Macular degeneration NOS,Rheumatoid arthritis,Hypoxemia,Pernicious anemia,Bone & cartilage dis NOS,Glaucoma NOS,Do not resusctate status,Long-term use steroids,Depend-supplement oxygen,Acq absence of organ NEC,History of tobacco use,Abn react-surg proc NEC,Abn react-cardiac cath,Adv eff diuretics NEC
Admission Date:  [**2123-1-12**]              Discharge Date:   [**2123-1-19**]

Date of Birth:  [**2047-9-27**]             Sex:   F

Service: MEDICINE

Allergies:
Tape [**12-14**]"X10YD / Morphine

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
- Cardiac catheterization [**2123-1-14**]

History of Present Illness:
75 F with CAD s/p to stent to RCA [**2116**], COPD recently started on
home oxygen, HTN, PVD who inititally presented to [**Hospital 1474**]
Hospital after for ongoing SOB since the beginning of [**Month (only) 404**].
Pt states that since early [**Month (only) 404**], she has been experiencing
worsening shortness of breath that has occurred on exercise & at
rest.  She has been unable to sleep or tolerate recumbency.  She
has had an ongoing cough productive of clear-white sputum
without hemoptysis.  She experienced one episode of chest
thightness/sharp chest pain roughly 3 weeks ago.  This pain was
non-radiation; it was not associated with diaphoresis, nausea,
vomiting.
.
She was seen by her PCP and started on inhalers for concern
regarding possible URI. On Monday, she was started on
azithromycin yesterday as well as home oxygen with a plan to
increase her prednisone.
.
Early on the morning of admission, she had worsening SOB/DOE so
she called 911 & was brought to [**Hospital 1474**] Hospital.  There was
iniital concern for a COPD exacerbation; she was given 250 mg
azithro, 1 gm cftx, albuterol/ipratropium nebs, IV solumedrol
125 mg IV. CXR showed bilateral effusions. CTA was negative for
PE.
.
Pt ruled in for NSTEMI (trop 2.76 -> 4.02).  She was given 325
mg ASA, plavix 75 mg, & she was started on heparin gtt.  She was
also given 40 mg IV lasix and subsequently transferred to [**Hospital1 18**]
for possible cath.
.
REVIEW OF SYSTEMS: As per HPI. No headache, dizziness, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, myalgias, or arthralgias. No history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery. No recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
PND, ankle edema, palpitations, syncope or presyncope.


Past Medical History:
-Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis


Social History:
- Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.

Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T= 95.6 BP= 135/69 HR= 105 RR= 18 O2 sat= 95% RA
GENERAL: thin elderly female, resting comfortably but fatigued
appearing, NAD
HEENT: NCAT. Sclera anicteric. Pupils equal, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. Slightly dry mucous membranes/
NECK: Supple with JVD to mandible.
CARDIAC: RRR, normal S1, S2. No m/r/g. Distant heart sounds.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds with bibasilar crackles, no wheezing or rhonchi.
ABDOMEN: Bowel sounds present, soft, non-tender, non-distended,
no organomegaly, no guarding or rebound tenderness.
EXTREMITIES: Warm, DPs 2+ bilaterally, no edema
SKIN: No stasis dermatitis or other rashes.
NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 throughout,
sensation grossly intact to light touch
PSYCH: Calm, appropriate

DISCHARGE PHYSICAL EXAM:
Tm: 98.5  100(70-100)  97/50(80-120/40-80)  18  98/2L
24 I/O: 1170/1100
GEN: Appears frail.
HEENT: NCAT.
NECK: No JVD
COR: +S1S2, RRR, no m/g/r.
PULM: Crackles at bases, do not clear with cough.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND.
EXT: WWP, no leg edema. R groin with hematoma stable.
NEURO: MAEE, weak.

Pertinent Results:
ADMISSION LABS & STUDIES:

[**2123-1-13**] 06:55AM BLOOD PT-13.2* PTT-VERIFIED B INR(PT)-1.2*
[**2123-1-13**] 06:55AM BLOOD WBC-9.4 RBC-3.95* Hgb-11.8* Hct-33.9*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.2 Plt Ct-290
[**2123-1-13**] 06:55AM BLOOD Glucose-100 UreaN-23* Creat-1.3* Na-140
K-3.6 Cl-100 HCO3-26 AnGap-18
[**2123-1-13**] 12:34AM BLOOD CK-MB-9 cTropnT-0.33*
[**2123-1-13**] 06:55AM BLOOD Calcium-8.8 Phos-5.8*# Mg-2.1

CXR ([**2123-1-14**]):
FINDINGS: Comparison is made with the most recent study at this
institution of [**2118-6-16**]. The cardiac silhouette remains somewhat
enlarged and there is increased opacification at the bases
consistent with small pleural effusions and associated
compressive atelectasis. There is engorgement of ill-defined
pulmonary vessels, consistent with elevated pulmonary venous
pressure, as suggested in the clinical history

CT ABDOMEN & PELVIS ([**2123-1-14**]):
IMPRESSION:
1. Left groin hematoma, deep to the left common femoral artery.
There is
mild stranding surrounding the right common femoral artery,
though no evidence of hematoma.
2. Diverticulosis.
3. New bilateral pleural effusions and smooth intralobular
septal thickening, likely indicating volume overload.
4. Extensive atherosclerosis.
5. Calcified granulomata in the liver and spleen.

DISCHARGE LABS & STUDIES:
[**2123-1-19**] 08:55AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-28 AnGap-15
[**2123-1-18**] 07:05AM BLOOD proBNP-9710*
[**2123-1-19**] 08:55AM BLOOD WBC-8.0 RBC-3.28* Hgb-9.9* Hct-29.1*
MCV-89 MCH-30.2 MCHC-34.0 RDW-14.4 Plt Ct-291

TTE ([**2123-1-13**]):The left atrium is mildly dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25-30
%) secondary to akinesis of the entire septum and apex, and
moderate global hypokinesis of the remaining segments. The
basal-mid lateral wall contracts best. Right ventricular chamber
size is normal. with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Severe global left ventricular systolic dysfunction
c/w multivessel CAD. Moderate mitral and tricuspid regurgitation
with moderate pulmonary artery systolic hypertension.


Brief Hospital Course:
REASON FOR HOSPITALIZATION:
75 F w CAD s/p RCA stent [**2116**], COPD, RA, seizure disorder, HTN,
PVD, p/w several weeks of worsening SOB. Ruled in for STEMI at
OSH & subsequently transferred to [**Hospital1 18**] for cath.

ACUTE DIAGNOSES:
# NSTEMI: Found to have peak troponin to 2.76 at OSH with T wave
changes in V2-V5.
Transferred on heparin gtt. Pt was continued on metoprolol,
statin, ASA. Loaded with plavix prior to cath on [**2123-1-14**] which
showed minimal in-stent restenosis of RCA stent, as well as a
tight ostial LAD on which PCI could not be performed (too
difficult). Pt had radial access for arterial cath; venous
access in groin difficult to obtain. Patient hypotensive during
case, requiring dopamine gtt temporarily (now off pressors).
Afterward, patient developed rapidly expanding left groin
hematoma. She was given protamine. Hematoma now stable,
hematocrit 29 on discharge (stable for days). Patient also
dyspnea, requiring O2 4L per NC, and appears somewhat volume
overloaded. Patient admitted to CCU for diuresis and observation
overnight. B/L LE US were negative for hematoma, non-contrast CT
abdomen and pelvis were negative for RP bleed.  In the CCU,
patient was continued on ASA 325mg PO, Atorvastatin 80mg PO
daily, Metoprolol tartrate 50mg PO BID, plavix.  Amlodipine was
discontinued and lisinopril was held due to hypotension/low
urine output.  On the floor, patient started on diovan 40 mg,
which should be held if her blood pressure is less than 100.
Discharged on full ASA, plavix, metoprolol succinate 100 mg QD.

# LEFT GROIN HEMATOMA: Developed apparent right groin hematoma
which was treated with protamine. CT [**Last Name (un) 103**] showed pt actually had
left groin hematoma, none on right. No pseudoaneurysm/RP bleed.
Hematoma and hematocrit remained stable throughout CCU & floor
course. DPs dopplerable BL. Patient was maintained on
pneumoboots instead of heparin sq prophylaxis.

# Acute on Chronic Systolic CHF: CXR showed pulmonary
engorgement & bilateral effusions with compressive atelectasis.
Pt was given IV lasix prior to going to the cath lab. A TTE was
performed that showed severe global hypokinesis & akinesis of
entire septum & apex.  LVEF 25-30%.  Prior ECHO shows EF 40-45%
in [**2116**]. During catheterization, pt was hypotensive & required
dopamine gtt.  She was transferred to the CCU for transient
hypotension requiring dopamine in the catheterization lab. Ms.
[**Known lastname 13143**] was normotensive on the floor. Diovan was started on
the floor as above.  Lasix will not be reinitiated on discharge.

CHRONIC DIAGNOSES:
# COPD/Emphysema: Pt was continued on her course of
azithromycin. There was no concern for acute exacerbatin given
good air movement & lack of wheeze.

# PVD: continued on aspirin & plavix.

# Seizure disorder: Last seizure was on [**2120**].  He was continued
on home keppra 1500mg [**Hospital1 **], but pharmacy recommended switching
her dose based on her renal function.  The recommended dose
(based on creatinine clearance) is 750 mg [**Hospital1 **].  This was
explained to the patient as she was nervous about the change in
dose.

# Rheumatoid arthritis:  He was continued on prednisone 5mg PO
daily.  Her celebrex was held due to NSTEMI.

# Osteopenia:  He was continued on calcium, vitamin D.

TRANSITIONAL ISSUES:
# Follow-Up:  Upon leaving rehab, the patient should schedule
follow up appointments with her cardiologist (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **])
and her primary care doctor.

# Code Status: DNR/DNI. Daughter is HCP: [**Name (NI) **] [**Name (NI) **]
[**Telephone/Fax (1) 28220**]

Medications on Admission:
Aspirin 81mg daily
Celebrex 100mg daily
Simvastatin 20mg nightly
Prednisone 5 mg daily
Metoprolol 25mg daily
Omeprazole 20mg daily
Amlodipine 5mg daily
Vitamin D 400 units daily
Calcium carbonate - 6 tabs daily
Keppra 1500mg [**Hospital1 **]
B12 injection once per month
Timolol 0.5% one drop to each eye daily in AM (not recently
taking)
Brimodidine 0.15% one drop left eye [**Hospital1 **] (not recently taking)
Optive dry eye solution, both eyes TID (not recently taking)


Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Please hold for sBP < 100 or HR < 60.
7. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please hold for sBP < 100.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough for 2 weeks.
12. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1)  Mucous
membrane five times a day as needed for sore throat for 1 weeks.

13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. calcium citrate 200 mg (950 mg) Tablet Sig: One (1) Tablet
PO three times a day.
16. Medication
B12 injections one per month
17. timolol maleate (PF) 0.5 % Dropperette Sig: One (1) drop
Ophthalmic QAM.
18. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
19. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
20. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO HS
(at bedtime) as needed for cough for 1 weeks: Do not administer
this medication if patient sedated.
21. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) as needed for congestion for 2 days.
22. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 27838**] Rehabilitation & [**Hospital **] Care Center - [**Hospital1 1474**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Non-ST Elevation Myocardial Infarction

SECONDARY DIAGNOSES:
- Congestive Heart Failure
- Coronary Artery Disease


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


Discharge Instructions:
Ms. [**Known lastname 13143**], it was a pleasure to participate in your care
while you were at [**Hospital1 18**].  You came to the hospital for shortness
of breath over hte past month. You were transferred from
[**Hospital 1474**] Hospital after it was found that you had a small heart
attack. While you were here, you had a cardiac catheterization
which showed a blockage.  We were unable to treat the blockage
because your blood pressure was low during the procedure and you
need to go to the cardiac intensive care unit.  While you were
there, you were treated with some intravenous diuretics.  Your
urine output temporarily dropped, but by the time you were
transferred back to the medical floor, your urine production
improved.  You had an ultrasound of your heart that showed
slight worsening of your heart failure.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

MEDICATION INSTRUCTIONS:
- Medications STARTED:
---> Please start taking celexa 10 mg daily
---> Please start taking diovan 40 mg daily
---> Please start taking atorvastatin 80 mg daily
---> Please start taking plavix 75 mg daily
---> Please start taking nasal saline spray as needed for dry
nose
---> Please start taking calcium citrate (instead of calcium
carbonate)
---> Please start taking your inhaler as indicated
- Medications STOPPED:
---> Please stop taking lisinopril
---> Please stop taking amlodipine
---> Please stop taking simvastatin
---> Please stop taking calcium carbonate
- Medications CHANGED:
---> Please decrease your dose of Keppra from 1500 mg twice a
day to 750 mg twice a day (this medication is now dosed safely
according to your kidney function)
---> Please increase your dose of aspirin from 81 mg to 325 mg
daily
---> Please increase your dose of metoprolol from 25 mg daily to
100 mg daily


Followup Instructions:
After you leave rehab, please call Dr.[**Name (NI) 5452**] office to schedule
a follow-up appointment.
{'Other complications due to other cardiac device, implant, and graft,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Hematoma complicating a procedure,Oliguria and anuria,Other iatrogenic hypotension,Other emphysema,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities with intermittent claudication,Percutaneous transluminal coronary angioplasty status,Macular degeneration (senile), unspecified,Rheumatoid arthritis,Hypoxemia,Pernicious anemia,Disorder of bone and cartilage, unspecified,Unspecified glaucoma,Do not resuscitate status,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Other acquired absence of organ,Personal history of tobacco use,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other diuretics 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

PRESENT ILLNESS: 75 F with CAD s/p to stent to RCA [**2116**], COPD recently started on
home oxygen, HTN, PVD who inititally presented to [**Hospital 1474**]
Hospital after for ongoing SOB since the beginning of [**Month (only) 404**].
Pt states that since early [**Month (only) 404**], she has been experiencing
worsening shortness of breath that has occurred on exercise & at
rest.  She has been unable to sleep or tolerate recumbency.  She
has had an ongoing cough productive of clear-white sputum
without hemoptysis.  She experienced one episode of chest
thightness/sharp chest pain roughly 3 weeks ago.  This pain was
non-radiation; it was not associated with diaphoresis, nausea,
vomiting.
.
She was seen by her PCP and started on inhalers for concern
regarding possible URI. On Monday, she was started on
azithromycin yesterday as well as home oxygen with a plan to
increase her prednisone.
.
Early on the morning of admission, she had worsening SOB/DOE so
she called 911 & was brought to [**Hospital 1474**] Hospital.  There was
iniital concern for a COPD exacerbation; she was given 250 mg
azithro, 1 gm cftx, albuterol/ipratropium nebs, IV solumedrol
125 mg IV. CXR showed bilateral effusions. CTA was negative for
PE.
.
Pt ruled in for NSTEMI (trop 2.76 -> 4.02).  She was given 325
mg ASA, plavix 75 mg, & she was started on heparin gtt.  She was
also given 40 mg IV lasix and subsequently transferred to [**Hospital1 18**]
for possible cath.
.
REVIEW OF SYSTEMS: As per HPI. No headache, dizziness, abdominal
pain, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, myalgias, or arthralgias. No history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery. No recent fevers, chills or
rigors. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
PND, ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: -Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis

MEDICATION ON ADMISSION: Aspirin 81mg daily
Celebrex 100mg daily
Simvastatin 20mg nightly
Prednisone 5 mg daily
Metoprolol 25mg daily
Omeprazole 20mg daily
Amlodipine 5mg daily
Vitamin D 400 units daily
Calcium carbonate - 6 tabs daily
Keppra 1500mg [**Hospital1 **]
B12 injection once per month
Timolol 0.5% one drop to each eye daily in AM (not recently
taking)
Brimodidine 0.15% one drop left eye [**Hospital1 **] (not recently taking)
Optive dry eye solution, both eyes TID (not recently taking)

ALLERGIES: Tape [**12-14**]"X10YD / Morphine

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T= 95.6 BP= 135/69 HR= 105 RR= 18 O2 sat= 95% RA
GENERAL: thin elderly female, resting comfortably but fatigued
appearing, NAD
HEENT: NCAT. Sclera anicteric. Pupils equal, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. Slightly dry mucous membranes/
NECK: Supple with JVD to mandible.
CARDIAC: RRR, normal S1, S2. No m/r/g. Distant heart sounds.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds with bibasilar crackles, no wheezing or rhonchi.
ABDOMEN: Bowel sounds present, soft, non-tender, non-distended,
no organomegaly, no guarding or rebound tenderness.
EXTREMITIES: Warm, DPs 2+ bilaterally, no edema
SKIN: No stasis dermatitis or other rashes.
NEURO: AAOx3, CN 2-12 grossly intact, strength 5/5 throughout,
sensation grossly intact to light touch
PSYCH: Calm, appropriate

FAMILY HISTORY: No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

SOCIAL HISTORY: - Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits. 

### Response:
{'Other complications due to other cardiac device, implant, and graft,Acute on chronic systolic heart failure,Subendocardial infarction, initial episode of care,Hematoma complicating a procedure,Oliguria and anuria,Other iatrogenic hypotension,Other emphysema,Epilepsy, unspecified, without mention of intractable epilepsy,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities with intermittent claudication,Percutaneous transluminal coronary angioplasty status,Macular degeneration (senile), unspecified,Rheumatoid arthritis,Hypoxemia,Pernicious anemia,Disorder of bone and cartilage, unspecified,Unspecified glaucoma,Do not resuscitate status,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Other acquired absence of organ,Personal history of tobacco use,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other diuretics causing adverse effects in therapeutic use'}
