CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: Ms. [**Known lastname **] is a 63 woman with hypertension and diabetes who was
in her usual state of health until about 3 weeks ago when she
awoke suddenly with shortness of breath. Her husband used his
nebulizer treatments on her to no avail. She was admitted to [**Hospital1 **] and diagnosed with AVNRT (full hx not entirely clear). At
discharge, the patient continued to feel short of breath,
nausea, and fatigue. She was so tired that she quit her job as a
monitor on a school bus.
.
She presented to her PCP who attempted to diarese her with
lasix, and treated a presumed PNA with ceftriaxone and steroids.
However, she noted decreased urine output and she continued to
feel fatigue and nausea. After 5 days of visiting her PCP's
office, the patient presented to [**Hospital3 **] on [**6-6**]
with dry heaves and shortness of breath. There, she was given
gram of rocephin, methylprednisolone, and 100 mg of doxycyline.
She was transferred to [**Hospital3 **] where she was discovered to be
in ARF with a creatinine of 4.3 up from her baseline of 1.5. She
was transfused 2 units PRBCs O+ blood on [**6-7**] for a hemolytic
anemia. Her creatinine continued to rise to 6.8 and her
platelets to fall, so she was transferred to [**Hospital1 18**] for
plasmapheresis for concern for TTP. Currently, she complains of
mild HA and admits to palpitations and chills. She has several
ecchymosis that she attributes to her last hospitalization
.
ROS: denies chest pain, fevers, confusion, hematuria,
hematochezia, dark urine, dysuria, pedal edema, visual changes,
tingling

MEDICAL HISTORY: DM
HTN
hypercholesterolemia
iron deficiency anemia
h.o c.diff
h.o PNA
left breast lumpectomy
diverticulitis
GERD
glaucoma

MEDICATION ON ADMISSION: Medications at Home:
- meformin 500 [**Hospital1 **]
- lisinopril 20 [**Hospital1 **]
- lexapro 10 mg HS
- vytorin 20 mg HS
- MVI QD
- avandia 8 mg QD
- norvasc 10 mg QD
- Cozaar 100 mg QD
- ASA 81 mg QD
.
Medications on TRANSFER from [**Hospital3 **]:
- zofran 4 mg IV Q8
- ferrous sulfate 325 mg QD
- regular insulin sliding scale
- protonix 40 mg QD
- duonebs 1 meb Q4 PRN SOB
- toprol XL 50 mg QD
- MVI QD
- lexapro 10 QHS
- norvasc 10 QD
- ASA 81 mg
.
Medications on TRANSFER from [**Hospital Unit Name 153**]:
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
- Insulin SC Sliding Scale
- Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
- Aluminum Hydroxide Suspension 30 ml PO BID
- Lorazepam 0.5-1 mg IV Q4H:PRN
- Calcium Acetate [**2112**] mg PO TID W/MEALS
- Maalox/Diphenhydramine/Lidocaine 30 ml PO TID:PRN nausea
- Diltiazem 120 mg PO QID
- Ondansetron 2-4 mg IV Q8H:PRN
- Pantoprazole 40 mg IV Q24H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.4, 163/62, HR 73, O2 91% on RA
Gen: pleasant, cooperative, slightly anxious
HEENT: dry MM, no scleral icterus
Neck: supple 7 cm JVD, no LAD
Cor: tachy, regular, no murmur
Pulm: CTAB, initially mild crackles at bases
Abd: obese, soft, NT, ND, + BS, no HSM
Ext: WWP, DP/PT 2+ bilaterally, strength upper and lower
extremities [**6-18**] bilaterally
Neuro: CN II-XII individually tested and intact
Skin: multiple ecchymosis on arms and shoulders, none on abdomen

FAMILY HISTORY: mother died with CRI and 1 functioning kidney. Her father died
of unknown causes. She has 3 brothers with arthritis, diabetes,
and asthma

SOCIAL HISTORY: denies EtOH, tobacco, illicits. Lives with husband who smokes.
Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acute kidney failure with lesion of tubular necrosis,End stage renal disease,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Pure hypercholesterolemia,Esophageal reflux,Old myocardial infarction
Mal hyp kid w cr kid V,Ac kidny fail, tubr necr,End stage renal disease,Oth nonauto hem anemia,Thrombocytopenia NOS,Systolic hrt failure NOS,DMII wo cmp uncntrld,Atrial fibrillation,Pure hypercholesterolem,Esophageal reflux,Old myocardial infarct
Admission Date:  [**2118-6-8**]              Discharge Date:   [**2118-6-23**]

Date of Birth:  [**2054-10-31**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
Internal Jugular Venous Dialysis Catheter Placement
Hemodialysis

History of Present Illness:
Ms. [**Known lastname **] is a 63 woman with hypertension and diabetes who was
in her usual state of health until about 3 weeks ago when she
awoke suddenly with shortness of breath. Her husband used his
nebulizer treatments on her to no avail. She was admitted to [**Hospital1 **] and diagnosed with AVNRT (full hx not entirely clear). At
discharge, the patient continued to feel short of breath,
nausea, and fatigue. She was so tired that she quit her job as a
monitor on a school bus.
.
She presented to her PCP who attempted to diarese her with
lasix, and treated a presumed PNA with ceftriaxone and steroids.
However, she noted decreased urine output and she continued to
feel fatigue and nausea. After 5 days of visiting her PCP's
office, the patient presented to [**Hospital3 **] on [**6-6**]
with dry heaves and shortness of breath. There, she was given
gram of rocephin, methylprednisolone, and 100 mg of doxycyline.
She was transferred to [**Hospital3 **] where she was discovered to be
in ARF with a creatinine of 4.3 up from her baseline of 1.5. She
was transfused 2 units PRBCs O+ blood on [**6-7**] for a hemolytic
anemia. Her creatinine continued to rise to 6.8 and her
platelets to fall, so she was transferred to [**Hospital1 18**] for
plasmapheresis for concern for TTP. Currently, she complains of
mild HA and admits to palpitations and chills. She has several
ecchymosis that she attributes to her last hospitalization
.
ROS: denies chest pain, fevers, confusion, hematuria,
hematochezia, dark urine, dysuria, pedal edema, visual changes,
tingling


Past Medical History:
DM
HTN
hypercholesterolemia
iron deficiency anemia
h.o c.diff
h.o PNA
left breast lumpectomy
diverticulitis
GERD
glaucoma


Social History:
 denies EtOH, tobacco, illicits. Lives with husband who smokes.

Family History:
mother died with CRI and 1 functioning kidney. Her father died
of unknown causes. She has 3 brothers with arthritis, diabetes,
and asthma

Physical Exam:
T 98.4, 163/62, HR 73, O2 91% on RA
Gen: pleasant, cooperative, slightly anxious
HEENT: dry MM, no scleral icterus
Neck: supple 7 cm JVD, no LAD
Cor: tachy, regular, no murmur
Pulm: CTAB, initially mild crackles at bases
Abd: obese, soft, NT, ND, + BS, no HSM
Ext: WWP, DP/PT 2+ bilaterally, strength upper and lower
extremities [**6-18**] bilaterally
Neuro: CN II-XII individually tested and intact
Skin: multiple ecchymosis on arms and shoulders, none on abdomen



Pertinent Results:
OSH labs from [**6-8**]:
.
9.5 WBC, HCT 31.1, Plt 114, few schistocytes, ESR 53, 2.3
retics,
BUN 140, creatinine 6.8, glucose 154
LDH 1591
Hgb A1C 5.8
.
CT scan at OSH: CHF, small pleural effusions, mild scattered
ground glass opacities, heterogeneous appearance of right lobe
of thyroid gland, left renal cyst.
.
EKG: a.fib with normal axis, normal QRS and QT intervals. No ST
changes or TWI.
.
CXR: AP view. My interpretation. ? small bilateral pleural
effusions and right lower lobe infiltrate
.
peripheral smear: [**2-15**] schistocytes per high power field. + Burr
cells, few platelets
.
[**2118-6-20**] CXR:
There is a dual lumen catheter, which has been tunneled via a
right internal jugular approach, replacing the temporary
catheter, which had been in placed on [**6-15**]. The tip
terminates in the right atrium. The cardiac and mediastinal
contours are unchanged. The lung volumes remain low, with mild
pulmonary vascular congestion. No pleural effusions are seen.
There is degenerative change at multiple levels of the spine.
.
IMPRESSION: Stable mild pulmonary vascular congestion. Temporary
dialysis catheter has been replaced with a tunneled dialysis
catheter in the interim since the prior study.
.
[**2118-6-20**] Renal biopsy:  The acute changes of thrombotic
microangiopathy are superimposed on considerable chronic
scarring and prominent chronic vascular injury (? chronic
hypertension and or prior episodes of TMA).
Light Microscopy:  The specimen consists of renal cortex and
medulla, containing approximately 15 glomeruli, of which 7 is
globally sclerotic.  The remainder show varying degrees of
compensatory hypertrophy and ischemic change.  Several thrombi
are noted.  Occasional double contours are seen.  Three [**Hospital1 **]
show segmental sclerosis.
.
There is moderate interstitial fibrosis and tubular atrophy that
appears even worse in the subcapsular zone.  Mild chronic
inflammation accompanies the scarring.
.
Arteries show marked intimal fibroplasia.
.
Arterioles show marked mural thickening, with frequent hyaline
change.  Several show varying degrees of mucoid intimal
hyperplasia and thrombus formation.
.
Immunofluorescence:  The specimen consists of renal cortex only,
containing approximately 5 glomeruli, of which 2 are globally
sclerotic.  There is no staining for IgG, IgA, IgM, Kappa,
Lambda, or C1q.  2+ C3 is seen along capillary loops and trace
in vessels. Albumin and fibrin (no thrombi) are
non-contributory.
.
Electron microscopy:  Findings will be issued in an addendum.
.
Comment:  The acute changes of thrombotic microangiopathy are
superimposed on considerable chronic scarring and prominent
chronic vascular injury (? chronic hypertension and or prior
episodes of TMA).


Brief Hospital Course:
Ms. [**Known lastname **] is a 63 year old woman with PMH of DM 2 and HTN who
presented with symptoms of SOB, nausea and fatigue, treated for
suspected pneumonia, who then presented to an outside hospital
with acute renal failure. She was transferred to [**Hospital1 18**] with ARF,
hemolytic anemia, and thrombocytopenia for possible
plasmapheresis out of concern for TTP. She was found to have a
hemolytic anemia, however peripheral blood examination and
further workup was not consistent with TTP, and the patient did
not undergo plasmapheresis. The patient required initiation of
hemodialysis for her renal failure.
.
# Acute renal failure: Renal failure in combination with the
hemolytic anemia initially raised the concern for TTP. Smear
showed few schistocytes (although somewhat difficult to
interpret as she had already been transfused PRBCs) consistent
with microangiopathic hemolytic anemia.  Renal ultrasound was
normal.  ADAMTS13 was sent and was not consistent with TTP as
etiology.  Although she did report diarrhea prior to her
transfer to [**Hospital1 18**], stool cultures were negative for E. coli,
campylobacter, salmonella, shigella, and yersinia, thus HUS also
seemed unlikely.  Autoimmune or drug-induced were also evaluated
as possibilities, however anti-GBM was negative and there were
no medications were clearly implicated.  [**Doctor First Name **]/ANCA were negative
in terms of vasculitis workup.  Complement levels were normal.
UPEP showed albumin only, no Bence [**Doctor Last Name 49**] proteins.  Renal biopsy
showed global and focal glomerulosclerosis and acute as well as
chronic TMA.  Anticardiolipin Abs were normal and lupus
anticoagulant was negative as potential causes of TMA as seen on
biopsy.  Given her history of poorly controlled hypertension, it
is thought that her renal disease and TMA is likely secondary to
malignant/poorly controlled hypertension.  She was initiated on
hemodialysis and, given results of renal biopsy showing
irreversible changes, outpatient hemodialysis was arranged.  She
was started on phosLo and renagel for phosphate lowering.  A
right tunnelled catheter was placed and venous mapping was
performed for future fistula placement.
.
# Anemia/Thrombocytopenia: Initial labs revealed grossly
elevated LDH and haptoglobin <20 and smear as above.
Fibrinogen, originally elevated as acute phase reactant,
normalized (never dropped below 100) and coags remained normal
so as not to suggest DIC.  Appeared to be microangiopathic
process, unlikely antibody mediated. Coombs negative and cold
agglutinins (for question of mycoplasma infection) were not
performed by lab as direct Coombs was negative.  Additionally,
mycoplasma serologies were negative.  Please see additional
workup as above.  Platelets normalized during her stay and her
hematocrit remained stable (27-30).  She required a total of 4U
prbcs throughout her stay (last transfusion [**6-17**]).  As above, she
did not undergo plasmapheresis as her presentation was not
deemed consistent with TTP.  Has received total 4U prbcs here
(and 2 at OSH); last transfusion [**6-17**].  Hemolysis labs revealed
decreasing LDH (previously grossly elevated) and normalized
haptoglobin (previously consistently <20).  CBC should be
monitored upon discharge.
.
# Hypoxia: During her stay, she maintained oxygen saturations in
the low to mid 90s on room air.  This was thought to be
multifactorial in the setting of fluid overload given oliguric
renal failure, HD dependent, and compressive atelectasis given
largely bedbound.  CXRs showed stable mild pulmonary vascular
congestion and renal team worked to remove additional fluid at
HD with some improvement in her O2 sats.  Infective process was
thought unlikely as she was without cough, elevated WBC count
and no focal infiltrates on CXR.  Despite low grade hypoxia and
new a. fib, her hypoxia was thought [**3-18**] to combination of above
factors and not with pulmonary embolism.
.
# Atrial fibrillation: A. fib new this hospitalization as she
was in NSR previously on EKGs from PCP's office.  The etiology
is not entirely clear, but is most likely a result of her
underlying acute illness and fluid overload causing atrial
dilatation.  She was started on diltiazem and lopressor and
rates remains in the high 90s to low 100s on max dose diltiazem
and 75mg PO lopressor tid.  Her CHADS score given DM2 and HTN
reveals 2.5% risk of stroke/year off anticoagulation, but
initiation of anticoagulation was originally held due to her
unclear hematologic picture and then for 1 week post renal
biopsy.  Cardiology was consulted and felt that current regimen
of diltiazem and lopressor was sufficient for now.  They
recommended 4 weeks of anticoagulation prior to possible attempt
at either pharmacologic for electrical cardioversion.  She is
scheduled for outpatient cardiology and should be started on
coumadin at rehabilitation on [**2118-6-27**] (which reflects one week
post renal biopsy) with goal of INR [**3-19**].
.
# Elevated ALT and alkaline phosphatase:  Were found to be
mildly elevated and given isolated ALT elevation (AST normal)
appeared more c/w drug etiology.  GGT was also up so alkaline
phosphatase was liver specific.  Hep C Ab negative, Hep B
serologies also negative (including Hep B surface Ab).
Discussed medication causes with pharmacy and it appeared most
likely secondary to frequent compazine administration for
nausea/vomiting.  Escitalopram and diltiazem can also cause LFT
abnormalities, but she had been on escitalopram without problems
on admission and her LFTs have since normalized despite
continued diltiazem.  With decreased need for compazine, LFTs
normalized.
.
# Hypertension: Her systolic blood pressure was originally
140-180 range and was reflection of longterm poorly controlled
hypertension (especially given [**Doctor First Name **] and renal TMA now thought
most probably secondary to malignant/poorly controlled HTN) as
well as fluid overload in the setting of oliguric renal failure.
 Her ACE-I was originally held with the thought renal process
was potentially reversible.  Despite lopressor and diltiazem
better rate controllers and less good blood pressure control,
her blood pressure improved to SBPs of 110s-130s consistently
with continued HD.  Thus, no additional agents were added back
for control.
.
# Nausea/vomiting:  Upon admission, she had nearly persistent
nausea and vomiting thought most likely a result of uremia as
her BUN was elevated to 100s range.  Her nausea improved with
continued HD, although she continues to experience bouts of N/V.
 She is however, tolerating PO food and fluids and her nausea
has been well controlled with ativan and phenergan.  She was
also started on reglan for improved motility.
.
# Type 2 diabetes mellitus: She was on oral agents at home with
good control as recent hemoglobin Ac1 was at goal.  Metformin
was discontinued given her renal failure.  Her blood sugar was
elevated when she began taking PO, but she was started on lantus
and continued on insulin sliding scale with improved control.
Her lantus can continue to be uptitrated as required.
.
# Depression/anxiety: She was continued on her outpatient dose
of lexapro with PRN ativan.
.
# PPX: Subcutaneous heparin, bowel regimen.
.
# FEN: Cardiac/[**Doctor First Name **]/renal diet, renagel and phoslo for
hyperphosphatemia
.
# Access/Tubes: Right tunnelled line in place. Left EJ.  No
foley.
.
# Communication: [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 19122**] [**Telephone/Fax (1) 72733**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19122**]
[**Telephone/Fax (1) 72734**] (C), [**Telephone/Fax (1) 72735**] (H)
.
# FULL CODE

Medications on Admission:
Medications at Home:
- meformin 500 [**Hospital1 **]
- lisinopril 20 [**Hospital1 **]
- lexapro 10 mg HS
- vytorin 20 mg HS
- MVI QD
- avandia 8 mg QD
- norvasc 10 mg QD
- Cozaar 100 mg QD
- ASA 81 mg QD
.
Medications on TRANSFER from [**Hospital3 **]:
- zofran 4 mg IV Q8
- ferrous sulfate 325 mg QD
- regular insulin sliding scale
- protonix 40 mg QD
- duonebs 1 meb Q4 PRN SOB
- toprol XL 50 mg QD
- MVI QD
- lexapro 10 QHS
- norvasc 10 QD
- ASA 81 mg
.
Medications on TRANSFER from [**Hospital Unit Name 153**]:
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
- Insulin SC Sliding Scale
- Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
- Aluminum Hydroxide Suspension 30 ml PO BID
- Lorazepam 0.5-1 mg IV Q4H:PRN
- Calcium Acetate [**2112**] mg PO TID W/MEALS
- Maalox/Diphenhydramine/Lidocaine 30 ml PO TID:PRN nausea
- Diltiazem 120 mg PO QID
- Ondansetron 2-4 mg IV Q8H:PRN
- Pantoprazole 40 mg IV Q24H


Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Vytorin [**12-3**] 10-20 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Zofran 2 mg/mL Solution Sig: Two (2) mg Intravenous every
6-8 hours as needed for nausea.
15. Prochlorperazine 10 mg IV Q6H:PRN nausea
16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
17. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for nausea.
18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-15**] Sprays Nasal
QID (4 times a day) as needed.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
20. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous at bedtime.
21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig:
variable  Subcutaneous four times a day: per sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
Acute on chronic renal failure
Initiation of hemodialysis for ESRD
Hemolytic anemia
Thrombocytopenia
Hypertension
.
Secondary:
Type 2 Diabetes mellitus
Hypercholesterolemia
GERD


Discharge Condition:
Stable hematocrit, platelets normalized, on regular HD schedule.


Discharge Instructions:
You were admitted with acute renal failure, anemia, low
platelets.  You were started on hemodialysis for your renal
failure and a renal biopsy was performed which showed the
process causing your renal failure is unlikely to reverse.  Your
platelet counts have normalized and your red blood cell count
has remained stable, although you are still anemic.
.
Please call your doctor or return to the emergency room if you
develop fevers/chills, shortness of breath, chest pain,
persistent nausea/vomiting, inability to tolerate food or fluids
or any other symptoms that concern you.
.
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.

Followup Instructions:
Please follow up with your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4899**], on
[**7-6**] at 1pm.
.
Please follow up with your kidney doctor, Dr. [**First Name (STitle) 805**] ([**Telephone/Fax (1) 806**] on [**7-19**] at 2pm.  Your appointment is in [**Last Name (un) **]
Diabetes Center on the [**Hospital Ward Name **] of [**Hospital1 **].
.
Please follow up with cardiology ([**Telephone/Fax (1) 9490**] on [**7-5**] at
9am with Dr. [**Last Name (STitle) 73**] in [**Hospital Ward Name 23**] building ([**Location (un) 436**]) on [**Hospital Ward Name **].


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acute kidney failure with lesion of tubular necrosis,End stage renal disease,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Pure hypercholesterolemia,Esophageal reflux,Old myocardial infarction'}


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: Ms. [**Known lastname **] is a 63 woman with hypertension and diabetes who was
in her usual state of health until about 3 weeks ago when she
awoke suddenly with shortness of breath. Her husband used his
nebulizer treatments on her to no avail. She was admitted to [**Hospital1 **] and diagnosed with AVNRT (full hx not entirely clear). At
discharge, the patient continued to feel short of breath,
nausea, and fatigue. She was so tired that she quit her job as a
monitor on a school bus.
.
She presented to her PCP who attempted to diarese her with
lasix, and treated a presumed PNA with ceftriaxone and steroids.
However, she noted decreased urine output and she continued to
feel fatigue and nausea. After 5 days of visiting her PCP's
office, the patient presented to [**Hospital3 **] on [**6-6**]
with dry heaves and shortness of breath. There, she was given
gram of rocephin, methylprednisolone, and 100 mg of doxycyline.
She was transferred to [**Hospital3 **] where she was discovered to be
in ARF with a creatinine of 4.3 up from her baseline of 1.5. She
was transfused 2 units PRBCs O+ blood on [**6-7**] for a hemolytic
anemia. Her creatinine continued to rise to 6.8 and her
platelets to fall, so she was transferred to [**Hospital1 18**] for
plasmapheresis for concern for TTP. Currently, she complains of
mild HA and admits to palpitations and chills. She has several
ecchymosis that she attributes to her last hospitalization
.
ROS: denies chest pain, fevers, confusion, hematuria,
hematochezia, dark urine, dysuria, pedal edema, visual changes,
tingling

MEDICAL HISTORY: DM
HTN
hypercholesterolemia
iron deficiency anemia
h.o c.diff
h.o PNA
left breast lumpectomy
diverticulitis
GERD
glaucoma

MEDICATION ON ADMISSION: Medications at Home:
- meformin 500 [**Hospital1 **]
- lisinopril 20 [**Hospital1 **]
- lexapro 10 mg HS
- vytorin 20 mg HS
- MVI QD
- avandia 8 mg QD
- norvasc 10 mg QD
- Cozaar 100 mg QD
- ASA 81 mg QD
.
Medications on TRANSFER from [**Hospital3 **]:
- zofran 4 mg IV Q8
- ferrous sulfate 325 mg QD
- regular insulin sliding scale
- protonix 40 mg QD
- duonebs 1 meb Q4 PRN SOB
- toprol XL 50 mg QD
- MVI QD
- lexapro 10 QHS
- norvasc 10 QD
- ASA 81 mg
.
Medications on TRANSFER from [**Hospital Unit Name 153**]:
- Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
- Insulin SC Sliding Scale
- Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
- Aluminum Hydroxide Suspension 30 ml PO BID
- Lorazepam 0.5-1 mg IV Q4H:PRN
- Calcium Acetate [**2112**] mg PO TID W/MEALS
- Maalox/Diphenhydramine/Lidocaine 30 ml PO TID:PRN nausea
- Diltiazem 120 mg PO QID
- Ondansetron 2-4 mg IV Q8H:PRN
- Pantoprazole 40 mg IV Q24H

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.4, 163/62, HR 73, O2 91% on RA
Gen: pleasant, cooperative, slightly anxious
HEENT: dry MM, no scleral icterus
Neck: supple 7 cm JVD, no LAD
Cor: tachy, regular, no murmur
Pulm: CTAB, initially mild crackles at bases
Abd: obese, soft, NT, ND, + BS, no HSM
Ext: WWP, DP/PT 2+ bilaterally, strength upper and lower
extremities [**6-18**] bilaterally
Neuro: CN II-XII individually tested and intact
Skin: multiple ecchymosis on arms and shoulders, none on abdomen

FAMILY HISTORY: mother died with CRI and 1 functioning kidney. Her father died
of unknown causes. She has 3 brothers with arthritis, diabetes,
and asthma

SOCIAL HISTORY: denies EtOH, tobacco, illicits. Lives with husband who smokes. 

### Response:
{'Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Acute kidney failure with lesion of tubular necrosis,End stage renal disease,Other non-autoimmune hemolytic anemias,Thrombocytopenia, unspecified,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial fibrillation,Pure hypercholesterolemia,Esophageal reflux,Old myocardial infarction'}
