CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: The patient is a 72 year old male with ESRD on HD, diastolic HF,
poorly controlled hypertension, and psoriasis who was BIBA from
home with increasing SOB throughout the day. He had a regularly
scheduled dialysis session on Friday, the day before admission
with about [**2133**] ml fluid removed. During the week, he had noted
increasing orthopnea and coughing when laying flat. He also had
some mild URI symptoms for 2-3 days with nasal congestion and
nonproductive cough but no fevers. The morning of admission, he
forgot to take his BP meds, and became increasingly SOB
throughout day. He is poorly compliant with his diet and ate
pizza with a friend for dinner. His SOB acutely worsened after
dinner, and he used his Lifeline upon arrival home. He was
brought in by EMS. His SPO2 had been in the low 90s on NRB but
improved to mid-90s on CPAP.
.
In the ED, he was afebrile, HR 130s, BP 200/110s, RR 30s, O2 sat
92% on CPAP. Labs were notable for WBC 20.7, bicarb 30,
electrolytes otherwise consistent with ESRD, and Troponin 0.19.
His EKG showed sinus tachycardia with LBBB unchanged from prior.
CXR showed pulmonary edema, bilateral pleural effusions, and
opacities likely representing atelectasis, though infection
could not be excluded. He was started on a Nitro drip and given
Lasix 80 mg IV x1, Ceftriaxone 1000 mg IV, Azithromycin, and
Labetolol 10mg IV x1. Renal service was consulted for emergent
dialysis. He was admitted to MICU [**Location (un) **].
.
On arrival to the MICU, initial vitals were HR 92, BP 156/77, O2
sat 98% on Bi-Pap. He stated that his breathing was comfortable
on BiPap. He denies subjective fevers/chills, chest pain,
pleuritic pain, nausea/vomiting, abdominal pain, diarrhea,
constipation, melena, or BRBPR. He was taken for emergent
dialysis with about [**2133**] ml fluid removed. After dialysis, he
felt much better with decreased SOB and improvement in his SpO2.
He was weaned off CPAP to face mask oxygen. He was given
Vancomycin, Cefepime, and Levofloxacin for possible HCAP, but
antibiotics were stopped earlier today given his lack of fevers
or sputum production and inconclusive CXR. His Troponin was
trended after admission, and rose from 0.19 on arrival to the
ED, 0.38 several hours later at midnight, and 0.53 at noon
today. He denied chest pain and EKG was unchanged, though
difficult to assess for ischemia given his baseline LBBB.
Dialysis is planned for tomorrow on his usual MWF schedule with
additional fluid removal.
.
When seen prior to floor transfer, he reported feeling much
better, and was sitting comfortably in a chair on 5L NC without
respiratory distress. He denied any current medical complaints.

MEDICAL HISTORY: - Hypertension - sees Dr. [**Last Name (STitle) 2204**]. Prior to [**8-4**], was last seen
in [**2138**].
- Chronic Renal Failure: thought to be from hypertension. MR [**First Name8 (NamePattern2) **] [**Location (un) 108084**]-vasculature in [**2133**] showed <50% stenosis of right renal
artery (not thought to be significant/flow limiting). Crt in
[**2138**] was 1.7. Next level is from [**8-4**], when pt found to have crt
of 5 and rising. Worsening renal function thought to be from
uncontrolled HTN. Dr. [**Last Name (STitle) **] is pt's nephrologist.
- Hyperlipidemia: Tot Chol 226, Tg 465, LDL 119, HDL 29. Not on

MEDICATION ON ADMISSION: Aspirin 81 mg PO every other day
Simvastatin 10 mg PO daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Metoprolol tartrate 100 mg PO BID
Doxazosin 2 mg PO BID
Dialyvite 800 0.8 mg 1 tab PO daily
Sensipar 30mg PO daily
Calcium acetate 667 mg PO TID
Trazodone 50 mg PO QHS
Hydrocodone-acetaminophen 5/500 1-2 tabs Q4-6H PRN pain
Allopurinol 100 mg PO daily
Docusate 100 mg PO daily
Senna 8.6mg PO BID PRN constipation
Bisacodyl 10 mg PO daily PRN constipation

ALLERGIES: Tetanus Toxoid,Adsorbed

PHYSICAL EXAM: VS: T 99.9, BP 150/58, HR 72, RR 17, SpO2 95% on 5L NC
Gen: Elderly male in NAD. Speaking in full sentences. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP elevated. No cervical
lymphadenopathy.
CV: RRR with occasional premature beats. Normal S1, S2. Soft
systolic murmur [**1-3**] at axilla.
Chest: Respiration unlabored. Decreased breath sounds
bilaterally with coarse crackles. Dullness at bases. No
egophony. No wheezes.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. LE edema 2+ bilaterally. Fingers
with DIP nodules. Distal pulses intact radial 2+, DP 2+.
Skin: Scattered plaques with silvery scale consistent with
psoriasis.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Mother had HTN & renal artery stenosis.

SOCIAL HISTORY: Lives alone. Divorced. Following his divorce, pt lost health
insurance & did not see a physician [**Name Initial (PRE) 767**] [**2138**] to [**2141-7-29**]. Pt
quit smoking tobacco >30yr ago. Does not drink ETOH or use
recreational drugs.
Acute on chronic combined systolic and diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Other and unspecified hyperlipidemia,Insomnia, unspecified
Ac/chr syst/dia hrt fail,End stage renal disease,Hyp kid NOS w cr kid V,Renal dialysis status,Hyperlipidemia NEC/NOS,Insomnia NOS
Admission Date:  [**2145-9-25**]              Discharge Date:   [**2145-9-29**]

Date of Birth:  [**2073-10-12**]             Sex:   M

Service: MEDICINE

Allergies:
Tetanus Toxoid,Adsorbed

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
hemodialysis


History of Present Illness:
The patient is a 72 year old male with ESRD on HD, diastolic HF,
poorly controlled hypertension, and psoriasis who was BIBA from
home with increasing SOB throughout the day. He had a regularly
scheduled dialysis session on Friday, the day before admission
with about [**2133**] ml fluid removed. During the week, he had noted
increasing orthopnea and coughing when laying flat. He also had
some mild URI symptoms for 2-3 days with nasal congestion and
nonproductive cough but no fevers. The morning of admission, he
forgot to take his BP meds, and became increasingly SOB
throughout day. He is poorly compliant with his diet and ate
pizza with a friend for dinner. His SOB acutely worsened after
dinner, and he used his Lifeline upon arrival home. He was
brought in by EMS. His SPO2 had been in the low 90s on NRB but
improved to mid-90s on CPAP.
.
In the ED, he was afebrile, HR 130s, BP 200/110s, RR 30s, O2 sat
92% on CPAP. Labs were notable for WBC 20.7, bicarb 30,
electrolytes otherwise consistent with ESRD, and Troponin 0.19.
His EKG showed sinus tachycardia with LBBB unchanged from prior.
CXR showed pulmonary edema, bilateral pleural effusions, and
opacities likely representing atelectasis, though infection
could not be excluded. He was started on a Nitro drip and given
Lasix 80 mg IV x1, Ceftriaxone 1000 mg IV, Azithromycin, and
Labetolol 10mg IV x1. Renal service was consulted for emergent
dialysis. He was admitted to MICU [**Location (un) **].
.
On arrival to the MICU, initial vitals were HR 92, BP 156/77, O2
sat 98% on Bi-Pap. He stated that his breathing was comfortable
on BiPap. He denies subjective fevers/chills, chest pain,
pleuritic pain, nausea/vomiting, abdominal pain, diarrhea,
constipation, melena, or BRBPR. He was taken for emergent
dialysis with about [**2133**] ml fluid removed. After dialysis, he
felt much better with decreased SOB and improvement in his SpO2.
He was weaned off CPAP to face mask oxygen. He was given
Vancomycin, Cefepime, and Levofloxacin for possible HCAP, but
antibiotics were stopped earlier today given his lack of fevers
or sputum production and inconclusive CXR. His Troponin was
trended after admission, and rose from 0.19 on arrival to the
ED, 0.38 several hours later at midnight, and 0.53 at noon
today. He denied chest pain and EKG was unchanged, though
difficult to assess for ischemia given his baseline LBBB.
Dialysis is planned for tomorrow on his usual MWF schedule with
additional fluid removal.
.
When seen prior to floor transfer, he reported feeling much
better, and was sitting comfortably in a chair on 5L NC without
respiratory distress. He denied any current medical complaints.

.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied current cough, improved shortness of breath. Denied chest
pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel habits. No black or bloody stool. Recent decrease in urine
output, denies any urinary discomfort. Chronic joint pain from
arthritis. Review of systems was otherwise negative.


Past Medical History:
- Hypertension - sees Dr. [**Last Name (STitle) 2204**]. Prior to [**8-4**], was last seen
in [**2138**].
- Chronic Renal Failure: thought to be from hypertension. MR [**First Name8 (NamePattern2) **] [**Location (un) 108084**]-vasculature in [**2133**] showed <50% stenosis of right renal
artery (not thought to be significant/flow limiting). Crt in
[**2138**] was 1.7. Next level is from [**8-4**], when pt found to have crt
of 5 and rising. Worsening renal function thought to be from
uncontrolled HTN. Dr. [**Last Name (STitle) **] is pt's nephrologist.
- Hyperlipidemia: Tot Chol 226, Tg 465, LDL 119, HDL 29. Not on

statin
- h/o elevated PSA: last value 3.3 on [**2141-8-16**], up from 2.1 in

[**2134**]


Social History:
Lives alone. Divorced. Following his divorce, pt lost health
insurance & did not see a physician [**Name Initial (PRE) 767**] [**2138**] to [**2141-7-29**]. Pt
quit smoking tobacco >30yr ago. Does not drink ETOH or use
recreational drugs.


Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had HTN & renal artery stenosis.

Physical Exam:
VS: T 99.9, BP 150/58, HR 72, RR 17, SpO2 95% on 5L NC
Gen: Elderly male in NAD. Speaking in full sentences. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP elevated. No cervical
lymphadenopathy.
CV: RRR with occasional premature beats. Normal S1, S2. Soft
systolic murmur [**1-3**] at axilla.
Chest: Respiration unlabored. Decreased breath sounds
bilaterally with coarse crackles. Dullness at bases. No
egophony. No wheezes.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. LE edema 2+ bilaterally. Fingers
with DIP nodules. Distal pulses intact radial 2+, DP 2+.
Skin: Scattered plaques with silvery scale consistent with
psoriasis.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.


Pertinent Results:
CBC
[**2145-9-25**] 08:45PM BLOOD WBC-20.7* RBC-4.29* Hgb-12.8* Hct-40.7
MCV-95 MCH-29.8 MCHC-31.4 RDW-15.6* Plt Ct-206
[**2145-9-26**] 01:07AM BLOOD WBC-14.0* RBC-3.66* Hgb-11.1* Hct-35.2*
MCV-96 MCH-30.4 MCHC-31.6 RDW-16.1* Plt Ct-164
[**2145-9-27**] 08:19AM BLOOD WBC-8.8 RBC-3.78* Hgb-11.3* Hct-35.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-15.8* Plt Ct-170

CHEM--7

[**2145-9-25**] 08:45PM BLOOD UreaN-43* Creat-8.3* Na-145 K-4.4 Cl-94*
HCO3-30 AnGap-25*

Cardiac enzymes:
[**2145-9-25**] 08:45PM BLOOD cTropnT-0.19*
[**2145-9-26**] 12:13AM BLOOD CK-MB-7 cTropnT-0.38*
[**2145-9-26**] 04:56AM BLOOD CK-MB-9 cTropnT-0.41*
[**2145-9-26**] 12:53PM BLOOD CK-MB-6 cTropnT-0.53*
[**2145-9-27**] 06:33AM BLOOD CK-MB-2 cTropnT-0.45*
.
Discharge Labs

IMAGING:
Portable CXR [**2145-9-25**]:
FINDINGS: There are moderate sized bilateral pleural effusions.
Bibasilar
opacification likely represents effusion and compressive
atelectasis, but
underlying consolidation cannot be excluded. Evaluation of the
cardiac
silhouette cannot be performed in the setting of these
opacities. No
pneumothorax is seen on this single view. Calcification of
aortic knob is
noted.

IMPRESSION: Bilateral pleural effusions and opacities likely
representing
efffusions and atelectasis, but underlying consolidation cannot
be excluded.

[**2145-9-29**] 06:21AM BLOOD WBC-7.6 RBC-3.69* Hgb-11.1* Hct-34.1*
MCV-92 MCH-30.0 MCHC-32.4 RDW-15.9* Plt Ct-215
[**2145-9-28**] 08:50AM BLOOD WBC-9.0 RBC-4.05* Hgb-12.2* Hct-39.0*
MCV-96 MCH-30.1 MCHC-31.2 RDW-16.0* Plt Ct-222
[**2145-9-27**] 08:19AM BLOOD WBC-8.8 RBC-3.78* Hgb-11.3* Hct-35.3*
MCV-93 MCH-29.8 MCHC-31.9 RDW-15.8* Plt Ct-170
[**2145-9-29**] 06:21AM BLOOD Neuts-74.5* Lymphs-12.7* Monos-4.1
Eos-7.6* Baso-1.0
[**2145-9-27**] 08:19AM BLOOD Neuts-79.4* Lymphs-10.5* Monos-4.3
Eos-4.8* Baso-1.0
[**2145-9-29**] 06:21AM BLOOD Plt Ct-215
[**2145-9-29**] 06:21AM BLOOD Glucose-93 UreaN-64* Creat-10.2*# Na-141
K-4.5 Cl-99 HCO3-26 AnGap-21*
[**2145-9-29**] 06:21AM BLOOD ALT-10 AST-17 LD(LDH)-167 CK(CPK)-35*
AlkPhos-64 Amylase-92 TotBili-0.3
[**2145-9-27**] 08:19AM BLOOD ALT-12 AST-18 LD(LDH)-172 CK(CPK)-37*
AlkPhos-61 Amylase-139* TotBili-0.4
[**2145-9-29**] 06:21AM BLOOD Lipase-51
[**2145-9-29**] 06:21AM BLOOD CK-MB-2 cTropnT-0.80*
[**2145-9-29**] 06:21AM BLOOD Albumin-3.9 Calcium-9.3 Phos-5.4* Mg-2.4
[**2145-9-28**] 08:50AM BLOOD Calcium-9.9 Phos-5.4* Mg-2.4
[**2145-9-25**] 08:46PM BLOOD Glucose-235* Lactate-1.4 K-4.3

Brief Hospital Course:
MICU Course
72M with h/o ESRD on HD, diastolic HF admitted to MICU for
hypoxia [**12-30**] pulmonary edema.

# Hypoxia: Likely [**12-30**] flash pulmonary edema (seen on CXR) in
setting of hypertension, ESRD and known chronic diastolic
dysfunction.  Also possible that he has concurrent pna given
recent cough and leukocytosis. Cardiac event unlikely given
unchanged EKG, trop mildly elevated but likely [**12-30**] renal
failure. He was given lasix 200mg IV x1 with little response. He
had emergent HD with 1.5L fluid removal.  His O2 requirement
significantly improved after HD, and on HD#2 he was maintaining
O2 sats >90% on NC.  He was also started on antibiotic coverage
for ?HCAP given he is on dialysis (vanc/zosyn/levo), however
these were discontinued as he improved significantly with HD.
Sputum cx and legionella Ag were pending at time of transfer to
the floor.

# Hypertensive crisis: BP elevated to 200s/100s with flash
pulmonary edema, likely due to not taking home BP meds on day of
admission.  His BP improved in the ED with IV labetolol, and he
was restarted on his home meds on HD#2.

# ESRD: Patient dialyzed on day PTA, on MWF dialysis schedule.
The renal service was consulted and he was emergently dialyzed
overnight for fluid removal.  He then resumed his normal HD
schedule.  He was continued on his home dialyvite, sensipar, and
calcium acetate.

# Leukocytosis: WBC on admission was 20, initially concerning
for possible HCAP.  However it rapidly improved to wnl,
suggesting most likely reactive.  He remained afebrile without
localizing sx of infection, and his antibiotics were
discontinued on HD#2.  Blood and urine cx were negative.

# CAD: Troponins were elelevated on admission (troponin 0.19,
CK-MB 2), thought likely [**12-30**] renal failure.  His enzymes were
trended and remained stable.  He was continued on his home ASA
81mg qod and simvastatin 10mg PO daily.
[**Hospital1 **] Floor Course
The patient is a 72 year old male with ESRD on HD, diastolic
Heart failure, and hypertension admitted to the MICU for hypoxia
due to flash pulmonary edema in the setting of dietary
noncompliance and missed BP meds.
.
# Hypoxia: His hypoxemia was most likely due to flash pulmonary
edema (seen on CXR) in the setting of hypertension, ESRD, and
known chronic diastolic dysfunction. There was also initial
concern for pneumonia given his leukocytosis, cough, and recent
URI symptoms, however he has been afebrile with no clear
consolidation on CXR. He was initially covered for a hospital
acquired pneumonia, but antibiotics were stopped earlier today
before callout. A cardiac event was possible given his rising
Troponin, though he denied chest pain. Demand ischemia was smore
likely. His EKG was unchanged from baseline, though difficult to
evaluate for ischemia given his baseline LBBB. His dyspnea and
SpO2 improved significantly after emergent dialysis with 2L
fluid removal.Persantine MIBI stress test did not show any new
ischemic changes.
.
# Hypertension: His BP was elevated to 200s/100s on ED arrival
with flash pulmonary edema, likely due to not taking home BP
meds in the morning. He was placed on a Nitro drip initially,
but quickly weaned off. His BP was controlled with Labetolol IV
and fluid removal in dialysis. Home meds were restarted on the
floor which included Lisinopril, Amlodipine, Doxazosin. His
Metoprolol Tartrate was increased to 150mg [**Hospital1 **].His BP remained
160-170/80-90's. Renal recommended to consider minoxidil 5 mg po
daily if BP remains high in the future.
.
# ESRD: He is typically on a MWF schedule, with an emergent
session Saturday shortly after arrival.Substiture Nephrocaps 1
tab PO daily  and Continued Sensipar 30 mg PO daily,Calcium
acetate 667 mg PO TID.
.
# Leukocytosis: Unclear whether reactive vs infectious. He is
currently afebrile but notes recent cough. There was initial
concern for pneumonia given his leukocytosis, cough, and recent
URI symptoms, however he has been afebrile with no clear
consolidation on CXR. He was initially covered for HCAP, but
antibiotics were stopped earlier before MICU callout. Urine
Legionella antigen was negative and sputum could not be
obtained.
.
# CAD: He was seen to have one vessel CAD with RCA involvement
on cardiac cath [**2143-8-20**]. His Troponin was elevated to 0.19 on ED
arrival, 0.38 several hours later at midnight, and 0.53 at noon
today. A cardiac event was possible given his rising Troponin,
but he denied chest pain. His CK and CK-MB were flat. Demand
ischemia due to his hypertension and hypoxia at presentation was
more likely. His EKG was unchanged from baseline, though
difficult to evaluate for ischemia given his baseline
LBBB.Continued home Aspirin 81 mg PO every other day Simvastatin
10 mg PO daily. p MIbi stress testing was negative for cardiac
ischemia.
.
# Insomnia:
-- Continued home Trazodone 50 mg PO QHS
.
Full code during this admission
.
Outpatient f/u
1) Titration of BP medications
2) continued workup for renal transplant
3) Conitnue Dialysis

Medications on Admission:
Aspirin 81 mg PO every other day
Simvastatin 10 mg PO daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Metoprolol tartrate 100 mg PO BID
Doxazosin 2 mg PO BID
Dialyvite 800 0.8 mg 1 tab PO daily
Sensipar 30mg PO daily
Calcium acetate 667 mg PO TID
Trazodone 50 mg PO QHS
Hydrocodone-acetaminophen 5/500 1-2 tabs Q4-6H PRN pain
Allopurinol 100 mg PO daily
Docusate 100 mg PO daily
Senna 8.6mg PO BID PRN constipation
Bisacodyl 10 mg PO daily PRN constipation


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every other day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. DIALYVITE 800 0.8 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Sensipar 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
11. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every 4-6 hours as needed for pain.
12. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: pulmonary edema
Secondary: Chronic Kidney Disease, hypertension


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname 47774**],

It was a pleasure taking care of you at the [**Hospital1 771**].  You were admitted with shortness of
breath at home.  You were treated with emergency dialysis and
oxygen in the intensive care unit, and your symptoms improved.
You were treated for high blood pressure.  We also evaluated you
with a persantine stress test, which was not concerning for
ischemic heart disease.

You continued on dialysis while you were a patient here.

We made the following changes to your home medications:
INCREASED Metoprolol to 150 mg twice daily.
INCREASED Lisinopril to 40 mg daily.

Please continue taking your other medications as usual.

Please followup with your doctors, see below.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] S.
Location: [**Hospital1 **] HEALTHCARE - [**State 3753**]GROUP
Address: [**State **], [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 2205**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 2204**]
within 1 week. You will be called at home with the appointment.
If you have not heard from the office within 2 days or have any
questions, please call the number above.**
.
Department: TRANSPLANT CENTER
When: TUESDAY [**2145-11-2**] at 9:20 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: THURSDAY [**2145-11-25**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
{'Acute on chronic combined systolic and diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Other and unspecified hyperlipidemia,Insomnia, 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: dyspnea

PRESENT ILLNESS: The patient is a 72 year old male with ESRD on HD, diastolic HF,
poorly controlled hypertension, and psoriasis who was BIBA from
home with increasing SOB throughout the day. He had a regularly
scheduled dialysis session on Friday, the day before admission
with about [**2133**] ml fluid removed. During the week, he had noted
increasing orthopnea and coughing when laying flat. He also had
some mild URI symptoms for 2-3 days with nasal congestion and
nonproductive cough but no fevers. The morning of admission, he
forgot to take his BP meds, and became increasingly SOB
throughout day. He is poorly compliant with his diet and ate
pizza with a friend for dinner. His SOB acutely worsened after
dinner, and he used his Lifeline upon arrival home. He was
brought in by EMS. His SPO2 had been in the low 90s on NRB but
improved to mid-90s on CPAP.
.
In the ED, he was afebrile, HR 130s, BP 200/110s, RR 30s, O2 sat
92% on CPAP. Labs were notable for WBC 20.7, bicarb 30,
electrolytes otherwise consistent with ESRD, and Troponin 0.19.
His EKG showed sinus tachycardia with LBBB unchanged from prior.
CXR showed pulmonary edema, bilateral pleural effusions, and
opacities likely representing atelectasis, though infection
could not be excluded. He was started on a Nitro drip and given
Lasix 80 mg IV x1, Ceftriaxone 1000 mg IV, Azithromycin, and
Labetolol 10mg IV x1. Renal service was consulted for emergent
dialysis. He was admitted to MICU [**Location (un) **].
.
On arrival to the MICU, initial vitals were HR 92, BP 156/77, O2
sat 98% on Bi-Pap. He stated that his breathing was comfortable
on BiPap. He denies subjective fevers/chills, chest pain,
pleuritic pain, nausea/vomiting, abdominal pain, diarrhea,
constipation, melena, or BRBPR. He was taken for emergent
dialysis with about [**2133**] ml fluid removed. After dialysis, he
felt much better with decreased SOB and improvement in his SpO2.
He was weaned off CPAP to face mask oxygen. He was given
Vancomycin, Cefepime, and Levofloxacin for possible HCAP, but
antibiotics were stopped earlier today given his lack of fevers
or sputum production and inconclusive CXR. His Troponin was
trended after admission, and rose from 0.19 on arrival to the
ED, 0.38 several hours later at midnight, and 0.53 at noon
today. He denied chest pain and EKG was unchanged, though
difficult to assess for ischemia given his baseline LBBB.
Dialysis is planned for tomorrow on his usual MWF schedule with
additional fluid removal.
.
When seen prior to floor transfer, he reported feeling much
better, and was sitting comfortably in a chair on 5L NC without
respiratory distress. He denied any current medical complaints.

MEDICAL HISTORY: - Hypertension - sees Dr. [**Last Name (STitle) 2204**]. Prior to [**8-4**], was last seen
in [**2138**].
- Chronic Renal Failure: thought to be from hypertension. MR [**First Name8 (NamePattern2) **] [**Location (un) 108084**]-vasculature in [**2133**] showed <50% stenosis of right renal
artery (not thought to be significant/flow limiting). Crt in
[**2138**] was 1.7. Next level is from [**8-4**], when pt found to have crt
of 5 and rising. Worsening renal function thought to be from
uncontrolled HTN. Dr. [**Last Name (STitle) **] is pt's nephrologist.
- Hyperlipidemia: Tot Chol 226, Tg 465, LDL 119, HDL 29. Not on

MEDICATION ON ADMISSION: Aspirin 81 mg PO every other day
Simvastatin 10 mg PO daily
Lisinopril 20 mg PO daily
Amlodipine 10 mg PO daily
Metoprolol tartrate 100 mg PO BID
Doxazosin 2 mg PO BID
Dialyvite 800 0.8 mg 1 tab PO daily
Sensipar 30mg PO daily
Calcium acetate 667 mg PO TID
Trazodone 50 mg PO QHS
Hydrocodone-acetaminophen 5/500 1-2 tabs Q4-6H PRN pain
Allopurinol 100 mg PO daily
Docusate 100 mg PO daily
Senna 8.6mg PO BID PRN constipation
Bisacodyl 10 mg PO daily PRN constipation

ALLERGIES: Tetanus Toxoid,Adsorbed

PHYSICAL EXAM: VS: T 99.9, BP 150/58, HR 72, RR 17, SpO2 95% on 5L NC
Gen: Elderly male in NAD. Speaking in full sentences. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP elevated. No cervical
lymphadenopathy.
CV: RRR with occasional premature beats. Normal S1, S2. Soft
systolic murmur [**1-3**] at axilla.
Chest: Respiration unlabored. Decreased breath sounds
bilaterally with coarse crackles. Dullness at bases. No
egophony. No wheezes.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Ext: Digital cap refill <2 sec. LE edema 2+ bilaterally. Fingers
with DIP nodules. Distal pulses intact radial 2+, DP 2+.
Skin: Scattered plaques with silvery scale consistent with
psoriasis.
Neuro: CN II-XII grossly intact. Strength 5/5 in all
extremities. Normal speech.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Mother had HTN & renal artery stenosis.

SOCIAL HISTORY: Lives alone. Divorced. Following his divorce, pt lost health
insurance & did not see a physician [**Name Initial (PRE) 767**] [**2138**] to [**2141-7-29**]. Pt
quit smoking tobacco >30yr ago. Does not drink ETOH or use
recreational drugs. 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Renal dialysis status,Other and unspecified hyperlipidemia,Insomnia, unspecified'}
