CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and HTN to the
190's.
.
She recently presented with similar symptoms of hypertensive
urgency c/b pulmonary edema requiring a brief intubation from
[**Date range (3) 96701**], then again from [**Date range (1) 96702**] for similar
presentation. During her admission on [**2143-3-6**], her home
nifedipine was discontinued and she was started on a BP regimen
of carvedilol/ lasix/ lisinopril. She was readmitted about a
week after with similar symptoms and findings consistent with
CHF exacerbation in setting for fluid overload, hypertension,
and flash pulmonary edema. She responded to BIPAP, lasix, nitro
gtt. She was discharged on Carvedilol 25mg by mouth twice a day.
The lisinopril was stopped at the time. Her discharge wt was
58.9 kg. She recently saw her PCP, [**Name10 (NameIs) 1023**] [**Name11 (NameIs) 15618**] her lasix to
40mg on [**2143-3-29**], and planned to restart her lisinopril later.

MEDICAL HISTORY: 1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
.
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]

MEDICATION ON ADMISSION: Aspirin 81 mg qd
Omeprazole 20 mg qd
Fluoxymesterone 10 mg [**Hospital1 **] - unable to get from manufactuer for
last several months, so not taking
Carvedilol 25 mg [**Hospital1 **]
Furosemide 40 mg qd
Scopolamine base 1.5 mg Patch q72 hr
Roxicet 5-325 mg q6 prn pain - patient states she is not taking

ALLERGIES: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

PHYSICAL EXAM: On Admission:
VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on
4L
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Slightly dry MM
NECK: Supple with JVP of 8 cm.
CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic
murmurs heard best at LUSB
LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast
tissue. Crackles at bases but otherwise good air movement.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees
bilaterally with chronic venous stasis changes.
SKIN: no rashes, + venous stasis changes
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from
coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister
with pancreatic cancer. Niece and nephew (in same family) both
with [**Name (NI) 4278**]. She is last surviving relative. HCP is his
lawyer.

SOCIAL HISTORY: She lives alone in [**Location (un) 96700**] and is very active at
baseline, independant in all ADL's, dives. Ambulates without
assisance. Spends Mon/Fri at the cultural center, Tues playing
trumpet in a band, and Weds/Thurs running erands. Has 3 cars at
home and drives. Retired teacher. Never married and without
children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine
<1x/week. No other drug use. No services at home currently.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None
Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Unspecified essential hypertension,Malignant neoplasm of other specified sites of female breast,Anemia, unspecified,Personal history of malignant neoplasm of large intestine,Esophageal reflux
Ac on chr diast hrt fail,Acute kidney failure NOS,Secondary malig neo bone,Secondary malig neo lung,Hypertension NOS,Malign neopl breast NEC,Anemia NOS,Hx of colonic malignancy,Esophageal reflux
Admission Date:  [**2143-4-8**]              Discharge Date:   [**2143-4-11**]


Service: MEDICINE

Allergies:
Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

Attending:[**Last Name (NamePattern1) 13129**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
None


History of Present Illness:
86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and HTN to the
190's.
.
She recently presented with similar symptoms of hypertensive
urgency c/b pulmonary edema requiring a brief intubation from
[**Date range (3) 96701**], then again from [**Date range (1) 96702**] for similar
presentation. During her admission on [**2143-3-6**], her home
nifedipine was discontinued and she was started on a BP regimen
of carvedilol/ lasix/ lisinopril. She was readmitted about a
week after with similar symptoms and findings consistent with
CHF exacerbation in setting for fluid overload, hypertension,
and flash pulmonary edema. She responded to BIPAP, lasix, nitro
gtt. She was discharged on Carvedilol 25mg by mouth twice a day.
The lisinopril was stopped at the time. Her discharge wt was
58.9 kg. She recently saw her PCP, [**Name10 (NameIs) 1023**] [**Name11 (NameIs) 15618**] her lasix to
40mg on [**2143-3-29**], and planned to restart her lisinopril later.

.
On the day of this admission, pt was shopping when she felt
sudden onset of SOB. She was BIBEMS placed on BIPAP in the
field. Found to be hypertensive to 190s sbp.
.
In the ED: VS: HR115 BP170/90 RR35 100% on BIPAP. EKG with no
acute changes with an old LBB and CXR with pulm edema. Pt was
given Aspirin, Nitro gtt, vancomycin, and 40 mg iv furosemide.
She also got vanc and zosyn as CXR could not exclude PNA. She
put out 950cc. She was initially going to be admitted to the CCU
for Bipap, but she was able to be weaned off the bipap and was
conversing comfortably on 4L NC. She was felt to be appropriate
for the floor. VS prior to transfer: 150/75 75 18 97% on 4L. On
nitro gtt with bp in the 130's
.
On arrival to the floor patient reports she is feeling much
better and no longer feel short of breath. She reports that she
has had no weight gain at home (weight was 60kg at home, dry
weight here 59kg). She denies increased [**Location (un) **] but states that her
legs are always swollen and slightly red on both sides.. At
baseline she sleeps in a recliner.
.
On review of systems, she denies any prior history of stroke,
TIA, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.

Past Medical History:
1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
.
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]

Social History:
She lives alone in [**Location (un) 96700**] and is very active at
baseline, independant in all ADL's, dives. Ambulates without
assisance. Spends Mon/Fri at the cultural center, Tues playing
trumpet in a band, and Weds/Thurs running erands. Has 3 cars at
home and drives. Retired teacher. Never married and without
children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine
<1x/week. No other drug use. No services at home currently.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None

Family History:
Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from
coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister
with pancreatic cancer. Niece and nephew (in same family) both
with [**Name (NI) 4278**]. She is last surviving relative. HCP is his
lawyer.

Physical Exam:
On Admission:
VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on
4L
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Slightly dry MM
NECK: Supple with JVP of 8 cm.
CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic
murmurs heard best at LUSB
LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast
tissue. Crackles at bases but otherwise good air movement.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees
bilaterally with chronic venous stasis changes.
SKIN: no rashes, + venous stasis changes
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

On Discharge:
VS: T=98.3 BP= 149/62 (120s - 140s/50s -70s) HR= 55 (65s-70s)
RR=18 O2 sat=97% on RA
Is&Os: Yesterday - 1620/2450 First 8 hour shift - 0/600
Weight: 61.8 <- 61.5
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric.
NECK: Supple, JVP not elevated.
CARDIAC: S1 S2, 3/6 systolic murmur
LUNGS: Moderate kyphosis. No accessory muscle use. Few basilar
crackles.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 1+ pitting edema
SKIN: no rashes, + venous stasis changes on LE b/l
GU: Foley catheter in place, urine appears grossly bloody
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

Pertinent Results:
Admission labs:
[**2143-4-8**] 08:10PM BLOOD WBC-8.2# RBC-4.61 Hgb-12.3 Hct-39.4
MCV-85 MCH-26.8* MCHC-31.4 RDW-15.7* Plt Ct-332
[**2143-4-8**] 08:10PM BLOOD Glucose-202* UreaN-29* Creat-1.2* Na-136
K-6.0* Cl-96 HCO3-26 AnGap-20
[**2143-4-8**] 08:10PM BLOOD Calcium-9.0 Phos-6.7*# Mg-2.7*

Discharge labs:
[**2143-4-11**] 04:35AM BLOOD WBC-6.3 RBC-3.58* Hgb-9.7* Hct-29.6*
MCV-83 MCH-27.0 MCHC-32.6 RDW-16.4* Plt Ct-261
[**2143-4-11**] 04:35AM BLOOD Glucose-107* UreaN-36* Creat-0.9 Na-138
K-4.1 Cl-100 HCO3-26 AnGap-16
[**2143-4-11**] 04:35AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.2

Other pertinent labs:
[**2143-4-9**] 03:30PM BLOOD CK(CPK)-92
[**2143-4-9**] 05:35AM BLOOD CK(CPK)-106
[**2143-4-9**] 03:30PM BLOOD CK-MB-4 cTropnT-0.02*
[**2143-4-9**] 05:35AM BLOOD CK-MB-6 cTropnT-0.04*
[**2143-4-8**] 08:10PM BLOOD cTropnT-0.01 proBNP-[**2104**]*
[**2143-4-9**] 05:35AM BLOOD TSH-2.9

[**2143-4-8**] EKG:
Very marked baseline artifact. Sinus tachycardia, rate 103.
Intraventricular conduction delay with left bundle-branch block
pattern and secondary ST-T wave changes. Compared to the
previous tracing of [**2143-3-18**] probably no diagnostic interval
change.

[**2143-4-8**] Portable CXR:
CHEST, AP: There has been increase in diffuse interstitial and
airspace
pulmonary opacities, with confluent opacification in the left
upper lobe and lingula, as well as the right perihilar region.
Moderate cardiomegaly is unchanged, with a tortuous and
calcified aorta. There are probable small bilateral pleural
effusions. The bones are diffusely demineralized, with
multilevel degenerative changes.
IMPRESSION: Increased pulmonary opacities, likely representing
worsening
congestive heart failure, although underlying consolidation from

infection/aspiration, mass is not excluded.

Renal ultrasound with doppler:
IMPRESSION:
1. Normal kidney size bilaterally. Incidental 8-mm right
angiomyolipoma.
Incomplete assessment of right renal vasculature but normal
brisk upstroke
arterial waveforms noted.
2. Normal left kidney with normal arterial and venous waveforms.

3. No evidence of renal arterial stenosis in either kidney.


Brief Hospital Course:
86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and hypertensive
urgency initially requiring bipap.  Patient now breathing
comfortably, blood pressure improved.

ACTIVE ISSUES
1. Acute Pulmonary Edema: Likely related to hypertensive
emergency as patient presented with SBPs in 190's. Patient had
crackles to mid lung field, peripheral edema, and evidence of
volume overload on CXR.  Initially patient was placed on bipap
in ED, butro gtt and iv lasix. Weaned quickly off bipap in ED
and was admitted to the cardiology service.  Patient initially
diuresed with IV lasix and blood pressure was controlled with
nitro gtt. Weaned off nitro gtt. Blood pressure control improved
(see below).  Patient diuresed well with IV lasix boluses and
was transitioned to PO lasix.  At discharge she was breathing
comfortably on room air and her peripheral edema had improved.
She was instructed to reduce sodium intake and weigh herself
every day.

2.  Hypertensive emergency: Patient has had three recent
hospitalizations for CHF likely related to hypertensive
emergency/urgency.  Patient was initially treated with nitro
gtt.  Her home dose of carvedilol was continued.  Lisinopril
dose was increased from 10 mg daily to 30 mg daily.  Patient was
started on spironolactone 25 mg daily.  Prior to discharge
patient's blood pressure control improved.

Work-up for secondary causes of hypertension was initiated in
hospital.  Patient had normal TSH.  She also had renal artery
ultrasound without evidence of renal artery stenosis.

3.  Anemia: Patient had HCT drop on admission, but remained
stable in the 29 - 30 range after admission.  She had some
hematuria with from foley trauma at admission, but not enough
hematuria to explain drop.  Patient's HCT remained stable.
Stools were guaiac negative.   Please continue outpatient anemia
work-up.

4. Acute Renal Failure: On admission, creatinine was slightly
elevated likely from poor forward flow in setting of acute
diastolic CHF.  Improved to baseline on day 2 of admission.

5. CAD: No documented cath in report, low suspicion for CAD.
Troponin elevated likely in setting of demand ischemia.  Peaked
at 0.04 and came down to 0.02. Patient had no chest pain.

CHRONIC/INACTIVE ISSUES
1. Breast CA: patient had been on oupatient regimen of
Fluoxymesterone but unable to obtain from manufactuer.
Patient's oncologist is aware and she will follow-up with her
oncologist.

2. CODE: Patient wished to be DNI but not DNR.  This was
discussed with patient as it is difficult to resuscitate someone
without intubating.  This should be further addressed with
patient.

TRANSITIONAL ISSUES:
1. Hypertensive emergency: Initiated work-up for secondary
causes of hypertension with TSH (normal) and Renal ultrasound
with dopplers that did not show renal artery stenosis.  Patient
to continue endocrine work-up for secondary causes of
hypertension as outpatient.

Medications on Admission:
Aspirin 81 mg qd
Omeprazole 20 mg qd
Fluoxymesterone 10 mg [**Hospital1 **] - unable to get from manufactuer for
last several months, so not taking
Carvedilol 25 mg [**Hospital1 **]
Furosemide 40 mg qd
Scopolamine base 1.5 mg Patch q72 hr
Roxicet 5-325 mg q6 prn pain - patient states she is not taking


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Monday [**2143-4-15**]. Please check chem 10.  Fax results to:
Name: [**Last Name (LF) 2204**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Phone: [**Telephone/Fax (1) 2205**]
Fax: [**Telephone/Fax (1) 7922**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
PRIMARY: Acute on chronic diastolic congestive heart failure
exacebation, hypertensive emergency
SECONDARY: Hypertension


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


Discharge Instructions:
It was a pleasure to participate in your care Ms. [**Known lastname 96703**].
You were admitted to the hospital because your blood pressure
was very high, you had too much fluid in your lungs, making it
difficult for you to breathe. You were given medications to help
remove the fluid from your body as well as lower your blood
pressure.  You felt much better and did not need any
supplemental oxygen to breath.  You blood pressure is also much
better.

Please have your blood drawn on Monday [**4-15**] prior to your
doctor's appointment on Tuesday [**4-16**] so that your doctor has
the information prior to your appointment.

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

Please make the following changes to your medications:
1. Increase your dose of lisinopirl to 30 mg daily from 10 mg
daily
2. Increase your dose of lasix to 40 mg twice a day from 40 mg
daily
3. ADD aldactone 25 mg daily

Please see below for your follow-up appointments.

Followup Instructions:
Department: [**State **]When: TUESDAY [**2143-4-16**] at 4:40 PM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking

Department: CARDIAC SERVICES
When: WEDNESDAY [**2143-4-24**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Unspecified essential hypertension,Malignant neoplasm of other specified sites of female breast,Anemia, unspecified,Personal history of malignant neoplasm of large intestine,Esophageal reflux'}


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: 86 F with PMH of metastatic breast ca, HTN, and dCHF who
presented to the ED with respirtory distress and HTN to the
190's.
.
She recently presented with similar symptoms of hypertensive
urgency c/b pulmonary edema requiring a brief intubation from
[**Date range (3) 96701**], then again from [**Date range (1) 96702**] for similar
presentation. During her admission on [**2143-3-6**], her home
nifedipine was discontinued and she was started on a BP regimen
of carvedilol/ lasix/ lisinopril. She was readmitted about a
week after with similar symptoms and findings consistent with
CHF exacerbation in setting for fluid overload, hypertension,
and flash pulmonary edema. She responded to BIPAP, lasix, nitro
gtt. She was discharged on Carvedilol 25mg by mouth twice a day.
The lisinopril was stopped at the time. Her discharge wt was
58.9 kg. She recently saw her PCP, [**Name10 (NameIs) 1023**] [**Name11 (NameIs) 15618**] her lasix to
40mg on [**2143-3-29**], and planned to restart her lisinopril later.

MEDICAL HISTORY: 1. CARDIAC RISK
FACTORS:(-)Diabetes,(-)Dyslipidemia,(+)Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Breast Cancer with mets to lung and bone, including skull
bone, stable on anti-estrogen therapy, primary oncologist (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96699**]) at [**Company 2860**]. Has lumpectomy and left-sided LN
dissection.
- H/o DVT on Fragmin (has h/o allergy to Lovenox), currently
dosed via [**Company 2860**] as part of a study protocol
- Hypertension
- [**Company **] cancer leading to a sigmoid resection in [**2109**]/[**2110**]
- OA - severe glenohumeral osteoarthritis plus other joints
- LUMBAR SPONDYLOSIS/SPINAL STENOSIS
- GERD
- Mild [**Doctor First Name **] Pos (1:40 titer) - clinically insignificant
- Past Cdiff Pos ([**2139**])
.
PAST SURGICAL HISTORY - per OMR
- s/p bilateral TKA
- L hip replacement, pins in right hip, most recent surgery [**1-17**]
yr ago
- S/p TAH in [**2098**]

MEDICATION ON ADMISSION: Aspirin 81 mg qd
Omeprazole 20 mg qd
Fluoxymesterone 10 mg [**Hospital1 **] - unable to get from manufactuer for
last several months, so not taking
Carvedilol 25 mg [**Hospital1 **]
Furosemide 40 mg qd
Scopolamine base 1.5 mg Patch q72 hr
Roxicet 5-325 mg q6 prn pain - patient states she is not taking

ALLERGIES: Augmentin / Tetanus / Biaxin / Clindamycin / Zometa / Enoxaparin
/ hydrochlorothiazide

PHYSICAL EXAM: On Admission:
VS: T=98 BP=159/66 on 215mcg nitro gtt HR=72 RR=24 O2 sat=97% on
4L
GENERAL: Well apeparing elderly F in NAD, breathing comfortably
and talking in complete sentences without difficulty
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Slightly dry MM
NECK: Supple with JVP of 8 cm.
CARDIAC: S1 S2 heard but difficult to discern over 4/6 systolic
murmurs heard best at LUSB
LUNGS: MOderate kyphosis, XRT mapping on skin, hard breast
tissue. Crackles at bases but otherwise good air movement.
ABDOMEN: Soft, NTND
EXTREMITIES: Warm, well perfused, 2+ pitting edema to knees
bilaterally with chronic venous stasis changes.
SKIN: no rashes, + venous stasis changes
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

FAMILY HISTORY: Mother had [**Name2 (NI) 499**] cancer, died at age [**Age over 90 **]. Father died at 49 from
coronary thrombosis. Sister with [**Name2 (NI) 499**] cancer. Another sister
with pancreatic cancer. Niece and nephew (in same family) both
with [**Name (NI) 4278**]. She is last surviving relative. HCP is his
lawyer.

SOCIAL HISTORY: She lives alone in [**Location (un) 96700**] and is very active at
baseline, independant in all ADL's, dives. Ambulates without
assisance. Spends Mon/Fri at the cultural center, Tues playing
trumpet in a band, and Weds/Thurs running erands. Has 3 cars at
home and drives. Retired teacher. Never married and without
children. Smoked 2ppd x 10-15 years until [**2094**], glass of wine
<1x/week. No other drug use. No services at home currently.
-Tobacco history: Past use, stopped [**2094**]
-ETOH: <1 glass/wk
-Illicit drugs: None 

### Response:
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Unspecified essential hypertension,Malignant neoplasm of other specified sites of female breast,Anemia, unspecified,Personal history of malignant neoplasm of large intestine,Esophageal reflux'}
