CHIEF COMPLAINT: transfer for bilateral pulmonary embolism

PRESENT ILLNESS: 67 y/o F with PMHx of Esophageal Dysmotility and Raynauds who
presented to an OSH with fatigue x 3wks found to have NSTEMI and
hypoxia. At the OSH CE were positive (CPK 95 CK mb 10.3 trop I
0.68 ). She was loaded with plavix, given ASA, ativan,
lopressor, nitro paste and started on a heparin GTT (7500 bolus,
1450 u/hr). The ECG at the OSH showed sinus tachycardia. She was
transferred to [**Hospital1 **] for further care.
In the [**Hospital1 18**] ED, initial vs were: T 98.7 P 103 BP 130/75 RR 24
O2 sat 89 RA. She underwent a CTA to eval for PE, given hypoxia
and tachycardia which revealed bilateral large PE's. The ECG
here showed sinus tach with non-specific TWF. She received 1L NS
and the heparin GTT was continued.
3 weeks ago the pt. received cortisone injections for back pain.
Since that time she has not felt well. She has experienced
flushing and "elevated BP. Last tuesday she had CP and took SL
NTG and ASA with good result. She went to [**Hospital **] hospital,
where ECG and CE were nromal per pt. She was sent home but still
had CP and DOE while climbing stairs. She also reports
palpitations. She again had chest pain this last Saturday and
presented to [**Hospital1 18**]. CE were normal and the ECG was normal. She
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol on Sunday which did not show any
ischemic changes. Her symptoms were thought to be due to GI
issues. She underwent an endoscopy on [**2184-3-10**]. Per the pt. her 02
sat after the procedure was 89% on RA. That night, she had a
pre-syncopal event at home and felt "she was dying." EMS was
called and she presented to [**Hospital **] hospital as above.
.
current vitals in ED 113/52, 98, 94% 3.5L, rr 20
.
Review of sytems:
She reports right calf pain since Sunday. She has felt unwell
for the past 3 weeks. + URI symptoms- productive cough. poor
appetite for 3 weeks. 17lbs weight loss over 3 weeks. CP, palps,
DOE, SOB, fatigue as in HPI. denies F/C/NS. no diarrhea, abd
pain, N/v, hemetemasis, BRBPR.

MEDICAL HISTORY: Hypertension
Raynauds
Esophageal Dysmotility Syndrome
Fibromyalgia
Arthritic Symptoms

MEDICATION ON ADMISSION: Alprazolam
Prevacid

ALLERGIES: Ranitidine / Prilosec / Aciphex / Paxil / Celexa / Prozac /
Zoloft / Cimetidine / Zestril / Lasix / Atenolol / Cozaar /
Celebrex / Reglan / Norvasc / Nexium / Carafate / Metoprolol /
Doxycycline / Hydrochlorothiazide / Triamterene

PHYSICAL EXAM: Vitals: T: 96.6 BP: 124/67 P: 98 R: 18 O2: 94% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral rales at bases L>R
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. slight right calf tenderness

FAMILY HISTORY: Son with h/o 2 PE's (has a PAI-1 mutation). 2 sisters with
clotting hx (1- DVT, 1- ?retinial thromobosis). Brother- MI at
68. 2 brothers with CA (esophageal CA, lymphoma)

SOCIAL HISTORY: She is married, does not smoke cigarettes or
drink alcohol. 2 children.
Other pulmonary embolism and infarction,Primary hypercoagulable state,Nontoxic uninodular goiter,Raynaud's syndrome,Myalgia and myositis, unspecified,Unspecified essential hypertension,Loss of weight,Dyskinesia of esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Systemic sclerosis,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified
Pulm embol/infarct NEC,Prim hypercoagulable st,Nontox uninodular goiter,Raynaud's syndrome,Myalgia and myositis NOS,Hypertension NOS,Abnormal loss of weight,Dyskinesia of esophagus,Gstr/ddnts NOS w/o hmrhg,Trachea & bronch dis NEC,Chr pulmon heart dis NEC,Systemic sclerosis,CHF NOS,Cardiac dysrhythmias NEC,Anxiety state NOS
Admission Date:  [**2184-3-11**]              Discharge Date:   [**2184-3-16**]

Date of Birth:  [**2116-9-7**]             Sex:   F

Service: MEDICINE

Allergies:
Ranitidine / Prilosec / Aciphex / Paxil / Celexa / Prozac /
Zoloft / Cimetidine / Zestril / Lasix / Atenolol / Cozaar /
Celebrex / Reglan / Norvasc / Nexium / Carafate / Metoprolol /
Doxycycline / Hydrochlorothiazide / Triamterene

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
transfer for bilateral pulmonary embolism

Major Surgical or Invasive Procedure:
none

History of Present Illness:
67 y/o F with PMHx of Esophageal Dysmotility and Raynauds who
presented to an OSH with fatigue x 3wks found to have NSTEMI and
hypoxia. At the OSH CE were positive (CPK 95 CK mb 10.3 trop I
0.68 ). She was loaded with plavix, given ASA, ativan,
lopressor, nitro paste and started on a heparin GTT (7500 bolus,
1450 u/hr). The ECG at the OSH showed sinus tachycardia. She was
transferred to [**Hospital1 **] for further care.
In the [**Hospital1 18**] ED, initial vs were: T 98.7 P 103 BP 130/75 RR 24
O2 sat 89 RA. She underwent a CTA to eval for PE, given hypoxia
and tachycardia which revealed bilateral large PE's. The ECG
here showed sinus tach with non-specific TWF. She received 1L NS
and the heparin GTT was continued.
3 weeks ago the pt. received cortisone injections for back pain.
Since that time she has not felt well. She has experienced
flushing and "elevated BP. Last tuesday she had CP and took SL
NTG and ASA with good result. She went to [**Hospital **] hospital,
where ECG and CE were nromal per pt. She was sent home but still
had CP and DOE while climbing stairs. She also reports
palpitations. She again had chest pain this last Saturday and
presented to [**Hospital1 18**]. CE were normal and the ECG was normal. She
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol on Sunday which did not show any
ischemic changes. Her symptoms were thought to be due to GI
issues. She underwent an endoscopy on [**2184-3-10**]. Per the pt. her 02
sat after the procedure was 89% on RA. That night, she had a
pre-syncopal event at home and felt "she was dying." EMS was
called and she presented to [**Hospital **] hospital as above.
.
current vitals in ED 113/52, 98, 94% 3.5L, rr 20
.
Review of sytems:
She reports right calf pain since Sunday. She has felt unwell
for the past 3 weeks. + URI symptoms- productive cough. poor
appetite for 3 weeks. 17lbs weight loss over 3 weeks. CP, palps,
DOE, SOB, fatigue as in HPI. denies F/C/NS. no diarrhea, abd
pain, N/v, hemetemasis, BRBPR.


Past Medical History:
Hypertension
Raynauds
Esophageal Dysmotility Syndrome
Fibromyalgia
Arthritic Symptoms


Social History:
She is married, does not smoke cigarettes or
drink alcohol. 2 children.


Family History:
Son with h/o 2 PE's (has a PAI-1 mutation). 2 sisters with
clotting hx (1- DVT, 1- ?retinial thromobosis). Brother- MI at
68. 2 brothers with CA (esophageal CA, lymphoma)

Physical Exam:
Vitals: T: 96.6 BP: 124/67 P: 98 R: 18 O2: 94% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral rales at bases L>R
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. slight right calf tenderness


Pertinent Results:
Labs:
Trop-T: 0.15 CK: 106 MB: 10 MBI: 9.4
.
137 102 11 BS 144 AGap=18
---------------
4.4 21 0.7
.
WBC 12.2 Hgb 14.3 Hct 40.5 Plts 241
N:76.4 L:19.9 M:2.6 E:0.7 Bas:0.3
.
PT: 13.0 PTT: 22.9 INR: 1.1
.
Images:
CTA [**2184-3-11**] Prelim- large bilateral PE's, small hiatal hernia,
thyroid nodule. recommend ultrasound on non-emergent basis
stable left lower lobe pulmonary nodule.
ETT [**2184-3-7**] INTERPRETATION: This 67 yo woman with uncontrolled
HTN was referred for evaluation of chest pain. The patient
performed 7 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol ~3.8 METs and stopped
for an exaggerated BP response and fatigue. This represents a
limited exercise tolerance. The patient presented with 3/10 left
upper chest "pressure", however before exercise, she denied this
symptom. No other symptoms were reported throughout the
procedure. In the presence of baseline non-specific ST-T waves,
there were no significant changes at peak exercise. Rhythm was
sinus without ectopy. Heart rate response to exercise was
appropriate.
IMPRESSION: Limited exercise tolerance. Exaggerated resting and
exercise BP. Non-anginal symptom with no significant EKG changes
from baseline.
.
EKG: rate 108 NSR, normal axis, q waves in III, aVF (new since
[**2184-3-7**]), low voltage in pre-cordial leads

INDICATION: 67-year-old female with shortness of breath since
endoscopy
yesterday with troponin bump at outside hospital. Evaluate for
pulmonary
embolus.

COMPARISON: [**2176-5-9**].

TECHNIQUE: Non-contrast and contrast-enhanced MDCT acquired
axial images of
the chest from the thoracic inlet to the upper abdomen.
Multiplanar
reformatted images were obtained.

FINDINGS: Large filling defects in the bilateral main pulmonary
arteries
extending into the segmental branches are compatible with
pulmonary embolus.
The thoracic aorta maintains a normal caliber and contour. The
main
pulnoary artery diameter equals that of the aorta, indicating
dialation. The
heart size is normal. There is dilatation of the right ventricle
compared to
the left with RV/LV ratio of 54:38 = 1.4 (normal 0.9) indicating
right
ventricular strain.

There is no pleural or pericardial effusion. The lungs show
diffuse
hypoventilatory change . 12 mm pulmonary nodule in the left lung
base which is
unchanged since the [**2176-5-9**]. The airways are patent to the
subsegmental
level however there is collapse of the airway on these apparent
expiratory
images suggestive of tracheobronchomalacia. There is no
mediastinal or
axillary lymphadenopathy. The visualized upper abdomen is
notable for a 2- cm
cyst in the interpolar region of the right kidney. Hypodense
nodules are
identified in each lobe of the thyroid for which further
evaluation with
ultrasound is recommended on a non-emergent basis. A small
hiatal hernia is
present. The bones show no lesions worrisome for osseous
metastases.

IMPRESSION:
1. Large bilateral PEs with evidence of right ventricular
strain.

2. Stable left lower lobe pulmonary nodule.

3. Bilateral hypodense nodule in the thyroid gland for which
further
evaluation with ultrasound is recommended on a non-emergent
basis.

4. Small hiatal hernia.

5. Collapse of the airways on apparent expiratory images is
suggestive of
underlying tracheobronchoalmalacia.

STUDY: Bilateral lower extremity veins ultrasound.

INDICATION: Bilateral pulmonary embolism and lower extremity
pain.

FINDINGS: Grayscale, color and pulse Doppler son[**Name (NI) 867**] was
performed on
bilateral common femoral, superficial femoral and popliteal
veins. Normal
flow, compression, augmentation and waveforms are demonstrated.
No
intraluminal thrombus detected.

IMPRESSION: No lower extremity DVT identified.

Provisional Findings Impression: [**Name (NI) 25790**] FRI [**2184-3-12**] 9:35 AM
Slightly limited examination of the lower common iliac seen
secondary to
patient body habitus. No definite evidence of intraluminal
thrombus within
the visualized venous system of the abdomen and pelvis.

2.3 cm right renal lesion, not completely characterized.
Followup
characterization by ultrasound or MRI is advised.
PFI AUDIT # 1 [**First Name9 (NamePattern2) 25790**] [**Doctor First Name **] [**2184-3-11**] 7:49 PM
Slightly limited examination of the lower common iliac seen
secondary to
patient body habitus. No definite evidence of intraluminal
thrombus within
the visualized venous system of the abdomen and pelvis.

Right renal lesion, definitely demonstrate to be a cyst by CT.
Followup
characterization by ultrasound or MRI is advised.


Preliminary Report !! PFI !!
Slightly limited examination of the lower common iliac seen
secondary to
patient body habitus. No definite evidence of intraluminal
thrombus within
the visualized venous system of the abdomen and pelvis.

2.3 cm right renal lesion, not completely characterized.
Followup
characterization by ultrasound or MRI is advised.

.
Findings
LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Increased
IVC diameter (>2.1cm) with <35% decrease during respiration
(estimated RA pressure (10-20mmHg).

LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). No resting LVOT gradient.

RIGHT VENTRICLE: Markedly dilated RV cavity. Severe global RV
free wall hypokinesis. Abnormal septal motion/position
consistent with RV pressure/volume overload.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Short (<140ms) transmitral E-wave
decel time.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Resting tachycardia (HR>100bpm).
Conclusions
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). The
right ventricular cavity is markedly dilated with severe global
free wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate to severe pulmonary artery systolic hypertension
(given elevated RA pressures). There is no pericardial effusion.


IMPRESSION: Dilated and hypokinetic right ventricle. Preserved
global and regional left ventricular systolic function. Moderate
to severe pulmonary hypertension. Moderate pulmonary
hypertension.



Brief Hospital Course:
(1) Bilateral Pulmonary Embolisms: While in the MICU she was
treated with Hep gtt and started on warfarin. Her O2 sats
gradually improved and her tachycardia resolved. She was
transitioned to lovenox [**Hospital1 **] and coumadin. Daily INR's were
checked with a goal of [**3-9**]. At discharge her INR was 2.3 and she
did not require further bridging with lovenox. She will continue
lifelong coumadin treatment. Her INR will be checked at local
lab and the results will be faxed to her PCP who will titrate
her coumadin dosing as appropriate.
-With strong FH of clots and no strong initiating factor for PE,
we were concerned for a genetic hypercoagulability work-up. We
sent hypercoagulability studies including Factor V Leiden,
prothrombin mutation analysis, Plasminogen Activator Inhibitor-1
Activity, homocysteine, anti-cardiolipin, lupus anticoagulant.
Some of these tests are still pending and will be followed up by
her primary care physician.

(2) Right heart failure: She had severe RV failure as well as
moderate pulmonary hypertension. This is likely the result of
the PE's causing increased stress on the right ventricle.
Initially it was thought that she had had an NSTEMI, however,
the troponin leak was likely secondary to dilation of RV and
NSTEMI medications, including plavix, were discontinued. She
will have a follow up appointment in the department of
cardiology for a repeat echo to monitor her recovery. She was
started on an ACE-I for cardiac protection as well as for
slightly elevated BPs (140s), however she developed a cough and
thus was switched to [**First Name8 (NamePattern2) **] [**Last Name (un) **].

(3) Sinus tachycardia: Likely secondary to PE's. Responded well
to IVF boluses.

(4) Renal cysts? : CT revealed renal lesion that was suspicious
for more than just a simple cyst. As per radiology
recommendations, performed renal ultrasound to evaluate lesion
which confirmed that this was just a simple cyst.

(5) Esophageal dysmotility: With reynauld's, there was a
question of whether the patient could have scleroderma which may
have contributed to hypercoagulability as well. Labs were sent
to evaluate for scleroderma and are pending at time of
discharge. She was continued on her home management for
esophageal dysphagia and her pcp will follow up the results of
the scleroderma labs.

(6) HTN: Stable throughout admit.

(7) Weight loss: 14-17 lb weight loss during last 3 weeks. Had a
Pan-CT scan for malignancy given the PEs. This was negative.
Patient is up to date on all cancer screening except her yearly
mammogram which she missed because her husband was [**Name2 (NI) **]. Breast
exam was WNL, however the patient will need to schedule a
mammogram to be performed after she is discharged from the
hospital.  She is aware of this and will do this upon discharge.

(8) Thyroid Nodules: Patient had CT scan that showed thyroid
nodules. It is recommended that she follow up with a thyroid
ultrasound to characterize these nodules. Her PCP will arrange
for this after discharge.


Medications on Admission:
Alprazolam
Prevacid


Discharge Medications:
1. Outpatient Lab Work
Please have INR check 2 days after discharge and again 2 days
later. Please have results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8522**] (fax:
[**Telephone/Fax (1) 25791**]). She will adjust the dose of your blood thinner,
warfarin, accordingly.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
3. Alprazolam 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times
a day) as needed.
4. Enoxaparin 100 mg/mL Syringe [**Last Name (STitle) **]: One (1) injection
Subcutaneous Q12H (every 12 hours).
Disp:*10 injection* Refills:*2*
5. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
6. Valsartan 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
as needed for HTN.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]

Discharge Diagnosis:
Bilateral Pulmonary Emboli


Discharge Condition:
The patient was afebrile, hemodynamically stable, and not
requiring oxygen prior to discharge.


Discharge Instructions:
You were admitted to the hospital with blood clots in your
lungs. We think you got these clots because you have a gene that
makes your blood thicker than normal. You were treated with a
blood thinner (warfarin) and will need to stay on this blood
thinner for the rest of  your life. You will need to have your
blood drawn to monitor the levels of this medication. Many other
medications can change the levels of the blood thinner so if you
start a new medication you will need to let your PCP know so
that they can change the dose of your blood thinner.
 Also, when you had your ct scan we found some nodules in your
thyroid gland. This is a common finding and usually benign,
however, we would like you to have a followup thyroid ultrasound
to make sure.

Medication Changes:
START: Warfarin 5mg by mouth daily
START: Valsartan 80mg by mouth daily

Please come back to the hospital or call your doctor if you have
fainting, headaches, vision changes, difficulty speaking,
shortness of breath, chest pain, palpitations, bloody or black
stools, weakness of your arms or legs, pain in your legs or any
other concerning symptoms.

Followup Instructions:
Please follow up with the cardiologist, Dr. [**First Name (STitle) 437**]
([**Telephone/Fax (1) 62**]), on Wednesday [**2184-3-31**] at 9am. He is located on
the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building at [**Hospital3 **] Hospital.
He will review the ultrasound of your heart and give you
appointments for another ultrasound to monitor your heart's
recovery.

Please follow up with your primary care doctor, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 8522**],
([**Telephone/Fax (1) 8577**]) on [**2184-3-23**] at 1:45. She will check your warfarin
level and adjust your dose accordingly.

Please have your blood drawn to check your warfarin levels 2
days after discharge using the prescription we have provided for
you. Please have the lab fax these results to Dr.[**Name (NI) 25792**]
office ([**Telephone/Fax (1) 25791**]). She will call you to tell you how much of
the blood thinner (warfarin) to take after she gets these
results.



Completed by:[**2184-3-16**]
{"Other pulmonary embolism and infarction,Primary hypercoagulable state,Nontoxic uninodular goiter,Raynaud's syndrome,Myalgia and myositis, unspecified,Unspecified essential hypertension,Loss of weight,Dyskinesia of esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Systemic sclerosis,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified"}


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: transfer for bilateral pulmonary embolism

PRESENT ILLNESS: 67 y/o F with PMHx of Esophageal Dysmotility and Raynauds who
presented to an OSH with fatigue x 3wks found to have NSTEMI and
hypoxia. At the OSH CE were positive (CPK 95 CK mb 10.3 trop I
0.68 ). She was loaded with plavix, given ASA, ativan,
lopressor, nitro paste and started on a heparin GTT (7500 bolus,
1450 u/hr). The ECG at the OSH showed sinus tachycardia. She was
transferred to [**Hospital1 **] for further care.
In the [**Hospital1 18**] ED, initial vs were: T 98.7 P 103 BP 130/75 RR 24
O2 sat 89 RA. She underwent a CTA to eval for PE, given hypoxia
and tachycardia which revealed bilateral large PE's. The ECG
here showed sinus tach with non-specific TWF. She received 1L NS
and the heparin GTT was continued.
3 weeks ago the pt. received cortisone injections for back pain.
Since that time she has not felt well. She has experienced
flushing and "elevated BP. Last tuesday she had CP and took SL
NTG and ASA with good result. She went to [**Hospital **] hospital,
where ECG and CE were nromal per pt. She was sent home but still
had CP and DOE while climbing stairs. She also reports
palpitations. She again had chest pain this last Saturday and
presented to [**Hospital1 18**]. CE were normal and the ECG was normal. She
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4001**] protocol on Sunday which did not show any
ischemic changes. Her symptoms were thought to be due to GI
issues. She underwent an endoscopy on [**2184-3-10**]. Per the pt. her 02
sat after the procedure was 89% on RA. That night, she had a
pre-syncopal event at home and felt "she was dying." EMS was
called and she presented to [**Hospital **] hospital as above.
.
current vitals in ED 113/52, 98, 94% 3.5L, rr 20
.
Review of sytems:
She reports right calf pain since Sunday. She has felt unwell
for the past 3 weeks. + URI symptoms- productive cough. poor
appetite for 3 weeks. 17lbs weight loss over 3 weeks. CP, palps,
DOE, SOB, fatigue as in HPI. denies F/C/NS. no diarrhea, abd
pain, N/v, hemetemasis, BRBPR.

MEDICAL HISTORY: Hypertension
Raynauds
Esophageal Dysmotility Syndrome
Fibromyalgia
Arthritic Symptoms

MEDICATION ON ADMISSION: Alprazolam
Prevacid

ALLERGIES: Ranitidine / Prilosec / Aciphex / Paxil / Celexa / Prozac /
Zoloft / Cimetidine / Zestril / Lasix / Atenolol / Cozaar /
Celebrex / Reglan / Norvasc / Nexium / Carafate / Metoprolol /
Doxycycline / Hydrochlorothiazide / Triamterene

PHYSICAL EXAM: Vitals: T: 96.6 BP: 124/67 P: 98 R: 18 O2: 94% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral rales at bases L>R
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. slight right calf tenderness

FAMILY HISTORY: Son with h/o 2 PE's (has a PAI-1 mutation). 2 sisters with
clotting hx (1- DVT, 1- ?retinial thromobosis). Brother- MI at
68. 2 brothers with CA (esophageal CA, lymphoma)

SOCIAL HISTORY: She is married, does not smoke cigarettes or
drink alcohol. 2 children. 

### Response:
{"Other pulmonary embolism and infarction,Primary hypercoagulable state,Nontoxic uninodular goiter,Raynaud's syndrome,Myalgia and myositis, unspecified,Unspecified essential hypertension,Loss of weight,Dyskinesia of esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Other diseases of trachea and bronchus,Other chronic pulmonary heart diseases,Systemic sclerosis,Congestive heart failure, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified"}
