CHIEF COMPLAINT: Reason for MICU admission: respiratory distress s/p intubation
in ED

PRESENT ILLNESS: This is an 85 year old man with PMH significant for HTN, CHF,
chronic kidney disease who presents with repiratory distress. He
had been hospitalized multiple times recently at [**Hospital1 18**],
beginning in [**11-24**] with a mechanical fall then re-presented that
month with pneumonia. In [**2-25**] he returned with a DVT in the
right common and deep common femoral veins and CHF exacerbation,
as well as troponin elevations and a bibasilar pneumonia.
.
He now presents following a fall at home. Per his wife and
notes, he was at home for the last three days following
discharge from rehab. He was reportedly sitting in a chair at
home, then fell off the chair. His wife found him on the ground,
awake and talking, and called EMS to get him to [**Hospital1 18**] for
evaluation. He did not have any obvioud trauma. His wife says he
noted chest heaviness and heart racing earlier in the day, and
had seemed short of breath since discharge from rehab.
.
In the ED, he was noted to be in respiratory distress, tachypnic
to 35, and O2 sat was 80%. His extremities were cool. He denied
chest pain, nausea, vomiting, incontinence, fevers, chills,
palpitations. Due to his respiratory distress, code status was
confirmed and the patient was intubated. Antibiotics were
started with vancomycin, levofloxacin, and flagyl, then blood
cultures were sent. CXR was felt to not have a striking
pneumonia. CT angiogram was considered but not done due to
elevated creatinine, and VQ scan was also considered. He got 1.8
liters of fluid and was empirically started on heparin because
his INR was 1.8, then transferred to the MICU.

MEDICAL HISTORY: 1. HTN
2. CKD: baseline around 2.3
3. bipolar disorder - on lithium previously
4. hyperlipidemia
5. prostate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not
know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF with EF [**2-25**] 30-40% with multiple hypokinetic walls
11. UTI's
12. Anemia
13. Possible reactive airway disease with response to prednisone
[**2-25**]
14. Hematuria
15. Pneumonia [**2-25**]

MEDICATION ON ADMISSION: Acetaminophen 325 mg Tablet PO Q4-6H
Aspirin 325 mg PO DAILY
Divalproex 125 mg PO QAM, 250 mg PO HS
Furosemide 40 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Metoprolol Tartrate 75 mg PO TID
Hydralazine 50 mg PO Q6H
Isosorbide Dinitrate 10 mg PO TID
Ipratropium Inhalation Q6H (every 6 hours) as needed.
Senna 8.6 mg PO BID
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Calcium Acetate 1334 mg PO three times a day: with meals.
Coumadin 4 mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V: T101.2 100/50 P85 98% AC 500x18 100%
Gen: intubated, sedated, in no distress
HEENT: pupils small, reactive
Neck: JVP elevated at 30 degrees
Resp: lungs with crackles diffusely bilaterally
CV: irreg irreg, normal S1s2 no murmurs
Abd: soft NTND +BS
Ext: cool extremities, 2+ pitting edema bilaterally
Neuro: sedated.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. Has 2 grown children, one is
[**State **] and one in [**State 760**]. Remote history of tobacco. No
alcohol.
Acute respiratory failure,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Unspecified essential hypertension,Asthma, unspecified type, unspecified,Old myocardial infarction,Bipolar I disorder, most recent episode (or current) unspecified
Acute respiratry failure,Chronic kidney dis NOS,Subendo infarct, initial,Atrial fibrillation,Rheumatic heart failure,Mitral/aortic val insuff,Gstr/ddnts NOS w hmrhg,Chr blood loss anemia,Hypertension NOS,Asthma NOS,Old myocardial infarct,Bipolor I current NOS
Admission Date:  [**2137-5-12**]              Discharge Date:   [**2137-5-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Reason for MICU admission: respiratory distress s/p intubation
in ED

Major Surgical or Invasive Procedure:
Endotracheal intubation
RIJ central line placement

History of Present Illness:
This is an 85 year old man with PMH significant for HTN, CHF,
chronic kidney disease who presents with repiratory distress. He
had been hospitalized multiple times recently at [**Hospital1 18**],
beginning in [**11-24**] with a mechanical fall then re-presented that
month with pneumonia. In [**2-25**] he returned with a DVT in the
right common and deep common femoral veins and CHF exacerbation,
as well as troponin elevations and a bibasilar pneumonia.
.
He now presents following a fall at home. Per his wife and
notes, he was at home for the last three days following
discharge from rehab. He was reportedly sitting in a chair at
home, then fell off the chair. His wife found him on the ground,
awake and talking, and called EMS to get him to [**Hospital1 18**] for
evaluation. He did not have any obvioud trauma. His wife says he
noted chest heaviness and heart racing earlier in the day, and
had seemed short of breath since discharge from rehab.
.
In the ED, he was noted to be in respiratory distress, tachypnic
to 35, and O2 sat was 80%. His extremities were cool. He denied
chest pain, nausea, vomiting, incontinence, fevers, chills,
palpitations. Due to his respiratory distress, code status was
confirmed and the patient was intubated. Antibiotics were
started with vancomycin, levofloxacin, and flagyl, then blood
cultures were sent. CXR was felt to not have a striking
pneumonia. CT angiogram was considered but not done due to
elevated creatinine, and VQ scan was also considered. He got 1.8
liters of fluid and was empirically started on heparin because
his INR was 1.8, then transferred to the MICU.


Past Medical History:
1. HTN
2. CKD: baseline around 2.3
3. bipolar disorder - on lithium previously
4. hyperlipidemia
5. prostate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not
know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF with EF [**2-25**] 30-40% with multiple hypokinetic walls
11. UTI's
12. Anemia
13. Possible reactive airway disease with response to prednisone
[**2-25**]
14. Hematuria
15. Pneumonia [**2-25**]


Social History:
Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. Has 2 grown children, one is
[**State **] and one in [**State 760**]. Remote history of tobacco. No
alcohol.

Family History:
Non-contributory

Physical Exam:
V: T101.2 100/50 P85 98% AC 500x18 100%
Gen: intubated, sedated, in no distress
HEENT: pupils small, reactive
Neck: JVP elevated at 30 degrees
Resp: lungs with crackles diffusely bilaterally
CV: irreg irreg, normal S1s2 no murmurs
Abd: soft NTND +BS
Ext: cool extremities, 2+ pitting edema bilaterally
Neuro: sedated.


Pertinent Results:
EKG: atrial fibrillation at rate of 98, ST depressions in V5 and
V6, likely J point elevation in V2/V3. LVH. Wide QRS -
interventricular conduction abnormality.
.
   RADIOLOGY  Final Report

BILAT LOWER EXT VEINS PORT  [**2137-5-13**] 9:13 AM

BILAT LOWER EXT VEINS PORT

Reason: SWOLLEN LEGS AND HYPOXIA

[**Hospital 93**] MEDICAL CONDITION:
85 year old man with swollen LEs and hypoxia.
REASON FOR THIS EXAMINATION:
?DVT
DOPPLER ULTRASOUND STUDY OF BOTH LOWER LIMB VEINS

CLINICAL DETAILS: Evaluate for deep venous thrombosis.

FINDINGS:

Right and left lower limb veins are patent and compressible with
phasic venous flow and increased venous return with augmentation
demonstrated on Doppler.

CONCLUSION:

1. No right or left lower limb deep venous thrombosis.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42121**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: MON [**2137-5-13**] 1:34 PM



.
    Cardiology Report ECHO Study Date of [**2137-5-13**]



PATIENT/TEST INFORMATION:
Indication: Congestive heart failure.
Weight (lb): 182
BP (mm Hg): 103/58
HR (bpm): 103
Status: Inpatient
Date/Time: [**2137-5-13**] at 13:11
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: Definity
Tape Number: 2006W000-0:00
Test Location: West MICU
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
  DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.5 cm
Left Ventricle - Fractional Shortening: *0.17 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 15% to 20% (nl >=55%)
Aorta - Valve Level: 2.8 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave Deceleration Time: 142 msec
TR Gradient (+ RA = PASP): *30 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

LEFT ATRIUM: Mild LA enlargement. Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Severe global LV
[**Name (STitle) 39407**]. Severely depressed LVEF. [Intrinsic LV systolic
function likely
depressed given the severity of valvular regurgitation.] No LV
mass/thrombus.

RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given
the severity of TR].

AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.

AORTIC VALVE: Mild to moderate ([**1-21**]+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Moderate (2+) MR.

TRICUSPID VALVE: Moderate [2+] TR. Borderline PA systolic
hypertension.

PERICARDIUM: No pericardial effusion.

Conclusions:
1. The left atrium is mildly dilated. The left atrium is
elongated. The right
atrium is moderately dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is severe global left ventricular
[**Month/Day (2) 39407**].
Overall left ventricular systolic function is severely
depressed. No masses or
thrombi are seen in the left ventricle. Intrinsic LV function
likely more
depressed given the mitral and aortic regurgitation.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal. [Intrinsic right ventricular systolic
function is likely
more depressed given the severity of tricuspid regurgitation.]
4. Mild to moderate ([**1-21**]+) aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral
regurgitation is seen.
6.Moderate [2+] tricuspid regurgitation is seen.
7.There is borderline pulmonary artery systolic hypertension.
8.There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2137-3-7**],
the MR is now worse and the anterior, inferior and inferolateral
walls are
more hypokinetic with a marked decrease in overall LV function.


Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2137-5-13**]
16:28.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].


([**Numeric Identifier 99680**])




.
   RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2137-5-12**] 7:50 PM

CHEST (PORTABLE AP)

Reason: r/o chf

[**Hospital 93**] MEDICAL CONDITION:
85 year old man with
REASON FOR THIS EXAMINATION:
r/o chf
INDICATION: Evaluate for CHF.

COMPARISON: [**2137-3-5**].

AP CHEST RADIOGRAPH

Study is limited by patient breathing. Cardiomegaly appears
unchanged. Mediastinal and hilar contours appear unchanged.
Increased opacities at the lower lobes bilaterally are seen.
There is slight increase in the pulmonary vascularity suggesting
mild CHF.

IMPRESSION: Increased lower lobe opacity bilaterally consistent
with aspiration or pneumonia. Mild CHF.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: MON [**2137-5-13**] 10:35 AM
.




[**2137-5-14**] 10:27 am SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

   GRAM STAIN (Final [**2137-5-14**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE ROD(S).

   RESPIRATORY CULTURE (Preliminary):
      ? OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    HEAVY GROWTH.
      GRAM NEGATIVE ROD(S).    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
.

BCX NGTD





Brief Hospital Course:
A/P: 85 year old man with recent history of CHF, pneumonia, DVT
in [**1-25**], admitted with acute shortness of breath requring
intubation in ED.
.
1. respiratory failure - DDx includes CHF, PE, pneumonia.
Initially with cool extremities suggestive of cardiogenic shock
but was found to be guaiac positive with falling Hct. Was on
anticoagulation for LE DVT; suspect he was anemic, developed AF,
then went into heart failure/pulm edema and resp failure and
then had an NSTEMI. Electively intubated in ED for hypoxia and
tachypnea. Bilateral pleural effusions on CXR, not tappable via
US [**5-13**]. Patient was extubated [**5-14**] without complication. PE not
excluded but patient will need long-term anticoagulation anyway
for his past DVT and AF. TTE [**5-13**] showed depressed EF 15-20%,
[**1-21**]+ AR, 2+MR/TR worsened MR [**First Name (Titles) **] [**Last Name (Titles) 39407**] of ant/inf/inflt
walls (Prior EF 30-40%). Amiodarone and digoxin were started;
amiodarone dosing should be changed to 400mg QD on [**5-21**]. Levo,
flagyl and vanco were initially started, then levo/flagyl d/c'd.
Vancomycin continued for coag-positive Staph aureus in sputum
(sensitivities still pending at time of discharge); he should
complete a full week (through [**2137-5-18**]) of vancomycin (1g Q48
hrs, hold for trough>15). His central line should be removed
after the last dose of vancomycin.
.
2. GIB - guaiac positive with melena [**5-12**]. No clear h/o GIBs but
has been on anticoagulation as an outpt for recent deep vein
thrombosis involving the right common femoral and deep femoral
veins [**2137-2-19**]. No NG lavage performed since Hct stable on [**5-14**]
and pt was just extubated. Patient received 2 units PRBC for
chronic anemia and drifting hct and was maintained on protonix
Q12 with slow advancement of diet to clears once hct stable. Pt
seen by GI; bleeding thought to be from ulcer/gastritis in
setting of anticoagulation, and EGD/colonoscopy deferred until
pt's respiratory status stabilizes and risk/benefit ratio is
more favorable. he should stay on [**Hospital1 **] protonix and can restart
his coumadin, and he only needs to follow-up with GI if he
develops more bleeding.
.
3. A fib - Pt had A fib on last EKG [**3-4**] but otherwise no
evidence of previous A fib by reports. Could be contributing to
CHF picture by reducing the atrial kick. TEE negative for
thrombus/effusion and EF 15-20% [**1-21**]+ AR, 2+ MR/TR and worsened
MR, inf/ant/infolateral [**Month/Day (2) 39407**]. Loaded w/IV amiodarone on
PO maintenance; dose should switch to 400mg PO QD on [**2137-5-21**]. A
digoxin level should be checked within a few days with
adjustment of dosage as necessary. Coumadin should be restarted
[**2137-5-16**] and INRs checked, with goal [**2-22**].
.
4. Elevated troponins with likely NSTEMI. Last NSTEMI [**2137-2-19**]
was started on ASA/plavix no stent/intervention. No h/o
stents/intervention. Has cardiac disease and was on medical
management. CK peaked at 193 on admission and have been
downtrending. TropT peaked at 0.82 [**5-13**]. Continue ASA, statin,
cont ACEi and titrate up as tolerated. Loaded with digoxin
(renally dosed for CrCl 31). He does not need to be on plavix as
he has no stents.
.
5. h/o HTN - hold hydralazine, isordil for now and titrate up
ACEi
.
6. chronic kidney disease at recent baseline of 2.6-3.0. Likely
has reduced forward flow in the setting of severe CHF. Weaned O2
keeping sat>93%. Diuresed with IV lasix based on clinical status
by day, with close monitoring of CVP and UOP.
.
7. h/o R LE DVT in [**1-25**] - Anticoagulation held in setting of
given guaiac positive stools. bilateral LENIs this admission neg
for DVT
.
8. anemia - MCV 97. send iron studies consistent with ACD likely
also component of iron deficiency. Threshold Hct<28 to
transfuse.
.
9. h/o bipolar disorder - continue valproate.
.
10. proph - Held anticoagulation until Hct stable, will restart
coumadin [**5-16**]. Pneumoboots, PPI [**Hospital1 **], bowel regimen, HOB>30
degrees, OOB to chair/PT consult
.
11. FEN - start clears and advance as tolerated
.
12. access - RIJ [**5-12**]; unable to get PIV on [**5-16**] so IJ left in
place; line should be pulled as soon as vancomycin is done with
placement of PICC or PIV as necessary
.
13. code status - Full
.
14. communication - with wife [**Telephone/Fax (1) 99681**] and son [**Telephone/Fax (1) 99682**]
.
15. dispo - transferred to [**Hospital3 105**] per family wishes

Medications on Admission:
Acetaminophen 325 mg Tablet PO Q4-6H
Aspirin 325 mg PO DAILY
Divalproex 125 mg PO QAM, 250 mg PO HS
Furosemide 40 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Metoprolol Tartrate 75 mg PO TID
Hydralazine 50 mg PO Q6H
Isosorbide Dinitrate 10 mg PO TID
Ipratropium Inhalation Q6H (every 6 hours) as needed.
Senna 8.6 mg PO BID
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Calcium Acetate 1334 mg PO three times a day: with meals.
Coumadin 4 mg PO QD

Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: Five (5) mL PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*100 mL* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
Disp:*600 mL* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
Disp:*180 Capsule(s)* Refills:*2*
7. Depakote 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QPM.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day): hold for SBP<100.
Disp:*45 Tablet(s)* Refills:*2*
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous  Q48H (every 48 hours): 7 days total (through
[**2137-5-18**]); last dose given [**2137-5-15**] at 6am; hold if trough > 15.
Disp:*15 gram* Refills:*2*
12. Amiodarone 200 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): for 1 week (last dose [**5-20**]), then decrease dose to
400mg PO QD.
Disp:*60 Tablet(s)* Refills:*2*
13. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day:
first dose [**2137-5-21**].
Disp:*30 Tablet(s)* Refills:*2*
14. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal [**2-22**].
Disp:*30 Tablet(s)* Refills:*2*
15. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Acute respiratory failure
GI bleed / Blood loss anemia
CHF
CRI (baseline 2.6-3.1)
Atrial fibrillation
Guiac-positive stool
NSTEMI
Anemia of chronic disease
Bipolar disorder


Discharge Condition:
Good


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml
Take all medications as directed.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2137-7-30**] 10:30
Call Dr. [**Last Name (STitle) 1266**] at [**Telephone/Fax (1) 608**] for an appointment 2 weeks
after you leave the hospital
{'Acute respiratory failure,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Unspecified essential hypertension,Asthma, unspecified type, unspecified,Old myocardial infarction,Bipolar I disorder, most recent episode (or current) 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: Reason for MICU admission: respiratory distress s/p intubation
in ED

PRESENT ILLNESS: This is an 85 year old man with PMH significant for HTN, CHF,
chronic kidney disease who presents with repiratory distress. He
had been hospitalized multiple times recently at [**Hospital1 18**],
beginning in [**11-24**] with a mechanical fall then re-presented that
month with pneumonia. In [**2-25**] he returned with a DVT in the
right common and deep common femoral veins and CHF exacerbation,
as well as troponin elevations and a bibasilar pneumonia.
.
He now presents following a fall at home. Per his wife and
notes, he was at home for the last three days following
discharge from rehab. He was reportedly sitting in a chair at
home, then fell off the chair. His wife found him on the ground,
awake and talking, and called EMS to get him to [**Hospital1 18**] for
evaluation. He did not have any obvioud trauma. His wife says he
noted chest heaviness and heart racing earlier in the day, and
had seemed short of breath since discharge from rehab.
.
In the ED, he was noted to be in respiratory distress, tachypnic
to 35, and O2 sat was 80%. His extremities were cool. He denied
chest pain, nausea, vomiting, incontinence, fevers, chills,
palpitations. Due to his respiratory distress, code status was
confirmed and the patient was intubated. Antibiotics were
started with vancomycin, levofloxacin, and flagyl, then blood
cultures were sent. CXR was felt to not have a striking
pneumonia. CT angiogram was considered but not done due to
elevated creatinine, and VQ scan was also considered. He got 1.8
liters of fluid and was empirically started on heparin because
his INR was 1.8, then transferred to the MICU.

MEDICAL HISTORY: 1. HTN
2. CKD: baseline around 2.3
3. bipolar disorder - on lithium previously
4. hyperlipidemia
5. prostate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not
know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF with EF [**2-25**] 30-40% with multiple hypokinetic walls
11. UTI's
12. Anemia
13. Possible reactive airway disease with response to prednisone
[**2-25**]
14. Hematuria
15. Pneumonia [**2-25**]

MEDICATION ON ADMISSION: Acetaminophen 325 mg Tablet PO Q4-6H
Aspirin 325 mg PO DAILY
Divalproex 125 mg PO QAM, 250 mg PO HS
Furosemide 40 mg PO DAILY
Clopidogrel 75 mg PO DAILY
Atorvastatin 80 mg PO DAILY
Metoprolol Tartrate 75 mg PO TID
Hydralazine 50 mg PO Q6H
Isosorbide Dinitrate 10 mg PO TID
Ipratropium Inhalation Q6H (every 6 hours) as needed.
Senna 8.6 mg PO BID
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg PO Q24H
Calcium Acetate 1334 mg PO three times a day: with meals.
Coumadin 4 mg PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: V: T101.2 100/50 P85 98% AC 500x18 100%
Gen: intubated, sedated, in no distress
HEENT: pupils small, reactive
Neck: JVP elevated at 30 degrees
Resp: lungs with crackles diffusely bilaterally
CV: irreg irreg, normal S1s2 no murmurs
Abd: soft NTND +BS
Ext: cool extremities, 2+ pitting edema bilaterally
Neuro: sedated.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. Has 2 grown children, one is
[**State **] and one in [**State 760**]. Remote history of tobacco. No
alcohol. 

### Response:
{'Acute respiratory failure,Chronic kidney disease, unspecified,Subendocardial infarction, initial episode of care,Atrial fibrillation,Rheumatic heart failure (congestive),Mitral valve insufficiency and aortic valve insufficiency,Unspecified gastritis and gastroduodenitis, with hemorrhage,Iron deficiency anemia secondary to blood loss (chronic),Unspecified essential hypertension,Asthma, unspecified type, unspecified,Old myocardial infarction,Bipolar I disorder, most recent episode (or current) unspecified'}
