CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 54 yo female with no significant past medical history presented
to OSH with progressive dyspnea. Per report collected from
husband, mother and [**Name (NI) **] nurse, the patient had symptoms of a URI,
ie dry cough, for about one week.  On the day of admission the
patient reported chest pain and dyspnea while driving home from
work.  EMS was called, and she was unable to speak in full
sentences.
.
Initial vitals on arrival to OSH 97.5 [**Telephone/Fax (3) 84559**]8 78% RA.
The patient had a CTA to rule out PE, which showed moderate
right and small left pleural effusions, diffuse ground-glass
densities, bibasilar consolidations.  PE, aortic dissection and
aneurysm were ruled out. Urinalysis, tox screen and LFTS were
normal.  At the OSH, her creatinine .9. BNP 2331 and troponin
.11. Pt was given 325mg ASA, NTG .4mg SLx3, lasix 40mg IV x2 and
put on BiPap. In short order, the pt was then intubated using
etomidate, vecc and succ and started on a nitro drip. Propofol
was used for sedation and a PEEP of 20 was noted. Pt
subsequently became hypotensive and was put on both levophed and
dobutamine drips. The patient was given ceftriaxone and azithro
for antibiotic coverage and a urine legionella was sent. A
central line was placed in the right femoral vein. The patient
was then transferred to [**Hospital1 **] for further management.
.
In the [**Hospital1 18**] ED, initial vitals, 98.8 92 105/82 28 100% on FiO2
100% Peep 20 RR 25set. Pressors were discontinued. EKG showed
sinus rhythm no signs of ischemia noted. Cardiology consulted
who initially recommended conservative management with repeat
enzymes and felt trop bump likely related to demand. CXR showed
bilateral process. Pt given vanc in addition to azithro and
ceftriaxone, and 4L IVFs. Pt was switched from propofol to
fentanyl/versed. A limited ultrasound was performed that did not
show any free fluid in the abdomen or pericardial effusion. Pt
also received 40meq KCL IV x1. Pt was also noted to be trace
guaiac positive.
.
The patient was admitted to the MICU initially.  Her vitals on
arrival were 100 88 148/91 28 100% FiO2 80%, Peep 16. Repeat EKG
showed T wave inversion in I and aVL. Cardiology [**Name (NI) 653**], EKGs
faxed, felt to be unchanged.  A TTE showed mod LVH, normal
cavity size, probable mild regional LV systolic dysfunction with
EF 55-60%, and basal inferior hypokinesis.  The patient was
taken to the cath lab and was found to have 3 vessel disease
with diffusely diseased LAD, OM stenosis and RCA stenosis.  Two
baremetal stents were placed in the RCA, and the other lesions
were unable to be intervened upon.  The patient was transferred
to the CCU for management of her coronary artery disease.  The
patient was ruled out for flu.
.
Unable to obtain a review of symptoms secondary to sedation and
intubation.

MEDICAL HISTORY: Arthritis

MEDICATION ON ADMISSION: Aleve prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL:  Sedated, intubated, arousable to stimuli.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother: Hypertension
Father: Deceased [**3-18**] "massive coronary."
PGF: Deceased [**3-18**] MI
Cousin, same age: CAD requiring CABG

SOCIAL HISTORY: Married. Her husband, [**Name (NI) **] is her health care proxy. Mother was a
former nurse here at the [**Hospital1 **]. [**First Name (Titles) **] [**Last Name (Titles) **] contacts. Pt is a
lawyer at the Federal Reserve Bank in [**Location (un) 86**]. She was fully
functional prior to admission.
-Tobacco history:  none
-ETOH:  none
-Illicit drugs:  none
Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Cerebral artery occlusion, unspecified with cerebral infarction,Encephalopathy, unspecified,Other pulmonary insufficiency, not elsewhere classified,Malignant essential hypertension,Coronary atherosclerosis of native coronary artery,Hypoxemia,Unspecified persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Other iatrogenic hypotension,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Nonspecific abnormal findings in stool contents,Anemia, unspecified,Family history of ischemic heart disease,Dermatophytosis of the body,Arthropathy, unspecified, site unspecified
Subendo infarct, initial,Ac diastolic hrt failure,Food/vomit pneumonitis,Crbl art ocl NOS w infrc,Encephalopathy NOS,Other pulmonary insuff,Malignant hypertension,Crnry athrscl natve vssl,Hypoxemia,Mental disor NOS oth dis,Chr pulmon heart dis NEC,Iatrogenc hypotnsion NEC,Adv eff opiates,Hypothyroidism NOS,Abn find-stool contents,Anemia NOS,Fam hx-ischem heart dis,Dermatophytosis of body,Arthropathy NOS-unspec
Admission Date:  [**2137-12-11**]              Discharge Date:   [**2137-12-23**]

Date of Birth:  [**2083-6-3**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
Cardiac catheterization with 2 bare metal stents to right
coronary artery
Endotracheal Intubation
Foley Catheter
Right Femoral Triple Lumen Central Venous Catheter
Right Radial Arterial Line


History of Present Illness:
54 yo female with no significant past medical history presented
to OSH with progressive dyspnea. Per report collected from
husband, mother and [**Name (NI) **] nurse, the patient had symptoms of a URI,
ie dry cough, for about one week.  On the day of admission the
patient reported chest pain and dyspnea while driving home from
work.  EMS was called, and she was unable to speak in full
sentences.
.
Initial vitals on arrival to OSH 97.5 [**Telephone/Fax (3) 84559**]8 78% RA.
The patient had a CTA to rule out PE, which showed moderate
right and small left pleural effusions, diffuse ground-glass
densities, bibasilar consolidations.  PE, aortic dissection and
aneurysm were ruled out. Urinalysis, tox screen and LFTS were
normal.  At the OSH, her creatinine .9. BNP 2331 and troponin
.11. Pt was given 325mg ASA, NTG .4mg SLx3, lasix 40mg IV x2 and
put on BiPap. In short order, the pt was then intubated using
etomidate, vecc and succ and started on a nitro drip. Propofol
was used for sedation and a PEEP of 20 was noted. Pt
subsequently became hypotensive and was put on both levophed and
dobutamine drips. The patient was given ceftriaxone and azithro
for antibiotic coverage and a urine legionella was sent. A
central line was placed in the right femoral vein. The patient
was then transferred to [**Hospital1 **] for further management.
.
In the [**Hospital1 18**] ED, initial vitals, 98.8 92 105/82 28 100% on FiO2
100% Peep 20 RR 25set. Pressors were discontinued. EKG showed
sinus rhythm no signs of ischemia noted. Cardiology consulted
who initially recommended conservative management with repeat
enzymes and felt trop bump likely related to demand. CXR showed
bilateral process. Pt given vanc in addition to azithro and
ceftriaxone, and 4L IVFs. Pt was switched from propofol to
fentanyl/versed. A limited ultrasound was performed that did not
show any free fluid in the abdomen or pericardial effusion. Pt
also received 40meq KCL IV x1. Pt was also noted to be trace
guaiac positive.
.
The patient was admitted to the MICU initially.  Her vitals on
arrival were 100 88 148/91 28 100% FiO2 80%, Peep 16. Repeat EKG
showed T wave inversion in I and aVL. Cardiology [**Name (NI) 653**], EKGs
faxed, felt to be unchanged.  A TTE showed mod LVH, normal
cavity size, probable mild regional LV systolic dysfunction with
EF 55-60%, and basal inferior hypokinesis.  The patient was
taken to the cath lab and was found to have 3 vessel disease
with diffusely diseased LAD, OM stenosis and RCA stenosis.  Two
baremetal stents were placed in the RCA, and the other lesions
were unable to be intervened upon.  The patient was transferred
to the CCU for management of her coronary artery disease.  The
patient was ruled out for flu.
.
Unable to obtain a review of symptoms secondary to sedation and
intubation.

Past Medical History:
Arthritis

Social History:
Married. Her husband, [**Name (NI) **] is her health care proxy. Mother was a
former nurse here at the [**Hospital1 **]. [**First Name (Titles) **] [**Last Name (Titles) **] contacts. Pt is a
lawyer at the Federal Reserve Bank in [**Location (un) 86**]. She was fully
functional prior to admission.
-Tobacco history:  none
-ETOH:  none
-Illicit drugs:  none

Family History:
Mother: Hypertension
Father: Deceased [**3-18**] "massive coronary."
PGF: Deceased [**3-18**] MI
Cousin, same age: CAD requiring CABG

Physical Exam:
GENERAL:  Sedated, intubated, arousable to stimuli.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of to the level of the mandible.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rales bilaterally
anteriorly, expiratory wheezes bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES:  2+ Bilateral lower extremity edema.  Arterial and
venous sheaths in place on the left.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
[**2137-12-11**] 01:40AM BLOOD WBC-13.6* RBC-4.00* Hgb-10.6* Hct-32.4*
MCV-81* MCH-26.5* MCHC-32.7 RDW-19.7* Plt Ct-387
[**2137-12-11**] 01:40AM BLOOD Glucose-132* UreaN-36* Creat-1.2* Na-143
K-3.0* Cl-108 HCO3-21* AnGap-17
[**2137-12-11**] 01:40AM BLOOD CK(CPK)-156*
[**2137-12-11**] 01:40AM BLOOD CK-MB-15* MB Indx-9.6* proBNP-3622*
[**2137-12-11**] 01:40AM BLOOD cTropnT-0.56*
[**2137-12-11**] 05:28AM BLOOD CK(CPK)-275*
[**2137-12-11**] 05:28AM BLOOD CK-MB-30* MB Indx-10.9* cTropnT-1.70*
[**2137-12-11**] 12:57PM BLOOD CK(CPK)-314*
[**2137-12-11**] 12:57PM BLOOD CK-MB-24* MB Indx-7.6* cTropnT-2.89*
[**2137-12-12**] 09:45AM BLOOD CK(CPK)-192*
[**2137-12-12**] 09:45AM BLOOD CK-MB-13* MB Indx-6.8* cTropnT-2.05*
[**2137-12-12**] 12:55AM BLOOD calTIBC-203* Ferritn-884* TRF-156*
[**2137-12-18**] 07:10AM BLOOD VitB12-1400* Folate-9.1
[**2137-12-11**] 05:28AM BLOOD %HbA1c-5.3
[**2137-12-11**] 05:28AM BLOOD Triglyc-99 HDL-36 CHOL/HD-4.1 LDLcalc-91
[**2137-12-18**] 07:10AM BLOOD TSH-34*
[**2137-12-18**] 07:10AM BLOOD Free T4-0.72*
[**2137-12-19**] 05:00AM BLOOD Cortsol-17.6
[**2137-12-11**] 01:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
   GRAM STAIN (Final [**2137-12-14**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2137-12-16**]):
      SPARSE GROWTH Commensal Respiratory Flora.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    SPARSE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA
                             |
TRIMETHOPRIM/SULFA----     2 S
.
CXR [**12-11**] - Bibasilar consolidations
.
EKG - NSR, TWIs I and aVL, suggestion of ST depression in
lateral leads, LVH
.
TELEMETRY:  Normal sinus rhythm at a rate of 70bpm
.
2D-ECHOCARDIOGRAM:  Suboptimal image quality. The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is probably mild regional left ventricular systolic dysfunction
with basal inferior hypokinesis. No masses or thrombi are seen
in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. An eccentric jet of at least mild (1+) mitral
regurgitation is seen. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
ETT:  none
.
CARDIAC CATH: LMCA ostial 20%, distal 20%
 LAD - calcified, diffuse disease, prox 30%, severe disease from
mid vessel onwards with calcified 80% disease at S3 after D1,
90% between S3 and S4, aneurysmal lesion after S4, diffuse
disease in the distal LAD to 80-90%, culminating in a 90%
stenosis in the apical LAD before it wraps around the apex.
 LCx - heavily calcified, ostial 20%, proximal 30-40% at OM3,
small OM1, modest caliber OM2, subtotal occlusion of small but
moderate length OM3, diffuse plaquing in mid LCx into large
LPL/OM4, 90% stenosis in distal AV groove CX into modest caliber
long OM5/LPL
 RCA - heavily calcified, proximal tubular 80% followed by mild
diffuse disease throughout the mid RCA with worse disease
beginning after modest AM2 to 85% in a diffusely diseased
segment involving a large lower AM (Perfusing the distal
inferior septum) with more diffuse disease in the distal AV
groove RCA supplying a branching RPDA and RPL as well as a
separate distal AV groove RCA beyond the RPDA, subtotal
occlusion of origin of AM2 with TIMI 2 flow in the AM2 and TIMI
2 fast flow into the RPDA.
.
HEMODYNAMICS:  moderate-severe elevation of PCW with severely
elevated LVEDP and moderate-severe pulmonary arterial
hypertension.
.
CT head [**12-18**]:
1. No evidence of hemorrhage, vascular territorial infarct, or
generalized
cerebral edema.

2. Small hypoattenuation foci in the right caudate
nucleus/corona radiata of indeterminate chronicity. While these
may represent chronic lacunar infarcts, more acute embolic
events cannot be totally excluded in this setting. These
findings could be better-characterized with MRI with diffusion
imaging if clinically indicated.


EEG
FINDINGS:
ABNORMALITY #1: Brief bursts of [**6-20**] Hz theta frequency slowing
were
seen involving the both temporal regions independently,
left>>right, and
synchronously.
ABNORMALITY #2: Occasional bursts of generalized [**6-20**] Hz theta
frequency
slowing was seen.
BACKGROUND: In the most organized portion of this tracing, a
moderately
well-organized [**10-24**] Hz alpha frequency background was seen.
HYPERVENTILATION: Was contraindicated due to the patient's
history of
cardiac disease.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested as a portable study.
SLEEP: There were no normal sleep or wake transitions seen.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate
of 72 bpm.
IMPRESSION: This is a mildly abnormal EEG due to the presence of
bursts
of independent and synchronous bitemporal slowing, suggesting
subcortical dysfunction in these areas. The presence of
occasional
bursts of generalized slowing suggests a mild encephalopathy or
extensive regions of bilateral deep or midline lesions. No
evidence of
ongoing seizures was seen.

MRI
1. Multifocal regions of restricted diffusion could represent
evolving
infarcts versus chronic microvascular white matter ischemic
disease with no
territorial infarct.
2. Multifocal regions of nodular enhancement, both superficial
and deep
within the brain parenchyma, including the left pons. Primary
differential
considerations include evolving enhancing infarcts versus
metastatic disease
and correlation with the patient's history is needed. Short-term
followup
examination to document stability and/or resolution of these
findings is
suggested.

IMPRESSION: As seen on the previous MRI of [**2137-12-19**] diffusion
images
demonstrate hyperintense areas with equivocal low signal on ADC
map indicative of acute/subacute infarcts. Some of the lesions
seen on diffusion images are too small to characterize but the
others demonstrate equivocal low signal on ADC to indicate
acute/subacute infarcts.

MRA HEAD:

The head MRA is limited by motion and covers only partially the
brain. Flow
signal is seen in the sylvian branches of both MCA and in both
anterior
cerebral arteries in A2 region.

IMPRESSION: Severely limited MRA provides no important
diagnostic
information. If clinically indicated repeat study can be
obtained.


Brief Hospital Course:
# CAD:  The patient has evidence of coronary artery disease and
likely had an NSTEMI within the last one to two days.  The
patient had 2 BMS placed in her RCA and is otherwise being
medically managed for her diffuse three vessel CAD, as the rest
of her CAD could not be intervened upon. Started on ASA, [**Date Range **]
(x at least 1 month), statin, BB. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) **] [**Last Name (Titles) 4319**]
or stop taking [**Last Name (Titles) **] unless Dr. [**Last Name (STitle) **] agrees with this plan.
.
# PUMP: Echo with preserved systolic function however cath shows
evidence of biventricular diastolic dysfunction. Initially had
symptoms of fluid overload but has been euvolemic with no signs
of CHF and stable weight for the last 5 days. Currently on no
diuretics. Will need TTE in 3 months.
.
#  Respiratory Distress:  Most likely [**3-18**] volume overload in the
setting of subacute NSTEMI and diastolic dysfunction.  However,
the patient has other radiology findings which point towards
consolidation.  Treated the patient for both CAP and pulmonary
edema with course of CTX + azithro, and aggressive diuresis with
lasix.  Flu negative.  Patient's respiratory status improved
significantly after several days of diuresis and patient was
extubated.  Of note, patient had significant hypertension with
SBP > 200 when attempting to wean sedation for extubation.
Patient had to be placed on nipride gtt to control BP during
weaning.  After successful extubation, patient was weaned off of
nipride and switched to PO anti-hypertensives. Sputum cx grew
out scant Stenotrophomonas, of unclear significance, not
treated.
.
# Hypertension: Following extubation, patient's BP was well
controlled on PO labetalol + lisinopril. As patient has had no
primary care for 15 years, unclear if this is long standing but
diastolic dysfunction suggests it is.
.
# Hypothyroidism:
TSH inc and T4 low. No known hx of hypothyroidism. Started PO
replacement. Cortisol level WNL. F/u TSH in [**2-15**] months.
.
# Confusion: Noted since extubation, initially thought [**3-18**] meds
however failed to resolve with time and space. CT head showed
old lacunar infarct, diffusion weighted MRI was suspicious for
acute/subactue stroke.  EEG showed mild encephalopathy with
bitemporal subcortical dysfunction, no seizure activity. Our
suspicion is that her labile and volatile bp changes at the OSH
with documented SBPs of 220 follow by 60 possibly lead to these
infarcts.  Her profound hypothyroidism may contribute.  Per
speech therapy, pt unable to follow more than simple commands,
has very poor short term memory and likely will be unable to
care for herself.  Neuro consult felt that her mental status is
slowly improving and she will f/u in the stroke clinic in 4
weeks. pt will need extensive OT support to help in her
cognitive recovery. Please see OT referral note.


Medications on Admission:
Aleve prn

Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Multivitamins with Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please take in am, on an empty stomach and 1 hour prior
to any food or other pills.
Disp:*30 Tablet(s)* Refills:*2*
10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): continue until one week after rash resolves.
Disp:*1 tube* Refills:*2*
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**2-15**] inhalations Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
inhalation Inhalation every six (6) hours as needed for
shortness of breath or wheezing.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Acute Diastoic congestive Heart Failure
Aspiration Pneumonia
Non-embolic cerebral vascular accident
Hypothyroidism
Tinea Corporis


Discharge Condition:
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Mental Status:Confused - always
Level of Consciousness:Alert and interactive


Discharge Instructions:
You had a heart attack and some fluid accumulation in your
lungs. You received 2 bare metal stents in your right coronary
artery. It is crucial that you take all of your medicines every
day and don't miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of your aspirin and [**Last Name (Titles) **]. You
will be on the following new medicines:
1. [**Last Name (Titles) **], a platelet medicine to keep the stent open.
2. Aspirin: to keep your stent open
3. Labetolol: a medicine to keep your blood pressure and heart
rate low
4. Lisinopril: a medicine to lower your blood pressure
5. Atorvastatin: a medicine to lower your cholesterol
6. Thiamine: a vitamin
7. Folic acid: a vitamin
.
During your stay, you were also noted to be more confused than
your baseline and having difficulty walking. MRI of the brain
revealed changes consistent with a stroke, possibly related to
episodes of severe hypertension that occurred at the beginning
of your hospitalization. Maintaining tight blood pressure
control is essential to prevent further damage to the brain. It
is essential that you continue the labetolol and lisinopril to
maintain control of your blood pressure. You will also need
rehabilitation from your stroke which will occur at rehab.
.
Additionally, you were found to have hypothyroidism during your
stay. You were started on levothyroxine (synthroid) once daily
and will need to have your thyroid function monitored by your
primary care physician [**Last Name (NamePattern4) **] 6 weeks. It is important that you
continue to take this medication, first thing in the morning, on
an empty stomach and 60 mins prior to any food or any of your
other medications.
.
You completed a seven day course of antibiotics for your
aspiration pneumonia and do not require further antiobiotics.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Follow a low sodium diet

Followup Instructions:
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 6522**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 250**] Friday,
[**12-27**] at 2:10pm. Their office is located in the [**Hospital Ward Name 23**]
Building, [**Location (un) **] on the [**Hospital Ward Name 516**] of [**Hospital1 18**].
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**2138-1-7**] 4:00.
Dr.[**Name (NI) 5907**] office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**]
Building, on the [**Hospital Ward Name 516**], [**Hospital1 18**].
.
Neurology:
Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) 1794**] ([**Telephone/Fax (1) 2528**] Date/Time: [**1-27**]
at 2:30pm. [**Hospital Ward Name 23**] clinical Center, [**Hospital Ward Name 516**], [**Location (un) 442**].
{'Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Cerebral artery occlusion, unspecified with cerebral infarction,Encephalopathy, unspecified,Other pulmonary insufficiency, not elsewhere classified,Malignant essential hypertension,Coronary atherosclerosis of native coronary artery,Hypoxemia,Unspecified persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Other iatrogenic hypotension,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Nonspecific abnormal findings in stool contents,Anemia, unspecified,Family history of ischemic heart disease,Dermatophytosis of the body,Arthropathy, unspecified, site 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: 54 yo female with no significant past medical history presented
to OSH with progressive dyspnea. Per report collected from
husband, mother and [**Name (NI) **] nurse, the patient had symptoms of a URI,
ie dry cough, for about one week.  On the day of admission the
patient reported chest pain and dyspnea while driving home from
work.  EMS was called, and she was unable to speak in full
sentences.
.
Initial vitals on arrival to OSH 97.5 [**Telephone/Fax (3) 84559**]8 78% RA.
The patient had a CTA to rule out PE, which showed moderate
right and small left pleural effusions, diffuse ground-glass
densities, bibasilar consolidations.  PE, aortic dissection and
aneurysm were ruled out. Urinalysis, tox screen and LFTS were
normal.  At the OSH, her creatinine .9. BNP 2331 and troponin
.11. Pt was given 325mg ASA, NTG .4mg SLx3, lasix 40mg IV x2 and
put on BiPap. In short order, the pt was then intubated using
etomidate, vecc and succ and started on a nitro drip. Propofol
was used for sedation and a PEEP of 20 was noted. Pt
subsequently became hypotensive and was put on both levophed and
dobutamine drips. The patient was given ceftriaxone and azithro
for antibiotic coverage and a urine legionella was sent. A
central line was placed in the right femoral vein. The patient
was then transferred to [**Hospital1 **] for further management.
.
In the [**Hospital1 18**] ED, initial vitals, 98.8 92 105/82 28 100% on FiO2
100% Peep 20 RR 25set. Pressors were discontinued. EKG showed
sinus rhythm no signs of ischemia noted. Cardiology consulted
who initially recommended conservative management with repeat
enzymes and felt trop bump likely related to demand. CXR showed
bilateral process. Pt given vanc in addition to azithro and
ceftriaxone, and 4L IVFs. Pt was switched from propofol to
fentanyl/versed. A limited ultrasound was performed that did not
show any free fluid in the abdomen or pericardial effusion. Pt
also received 40meq KCL IV x1. Pt was also noted to be trace
guaiac positive.
.
The patient was admitted to the MICU initially.  Her vitals on
arrival were 100 88 148/91 28 100% FiO2 80%, Peep 16. Repeat EKG
showed T wave inversion in I and aVL. Cardiology [**Name (NI) 653**], EKGs
faxed, felt to be unchanged.  A TTE showed mod LVH, normal
cavity size, probable mild regional LV systolic dysfunction with
EF 55-60%, and basal inferior hypokinesis.  The patient was
taken to the cath lab and was found to have 3 vessel disease
with diffusely diseased LAD, OM stenosis and RCA stenosis.  Two
baremetal stents were placed in the RCA, and the other lesions
were unable to be intervened upon.  The patient was transferred
to the CCU for management of her coronary artery disease.  The
patient was ruled out for flu.
.
Unable to obtain a review of symptoms secondary to sedation and
intubation.

MEDICAL HISTORY: Arthritis

MEDICATION ON ADMISSION: Aleve prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL:  Sedated, intubated, arousable to stimuli.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother: Hypertension
Father: Deceased [**3-18**] "massive coronary."
PGF: Deceased [**3-18**] MI
Cousin, same age: CAD requiring CABG

SOCIAL HISTORY: Married. Her husband, [**Name (NI) **] is her health care proxy. Mother was a
former nurse here at the [**Hospital1 **]. [**First Name (Titles) **] [**Last Name (Titles) **] contacts. Pt is a
lawyer at the Federal Reserve Bank in [**Location (un) 86**]. She was fully
functional prior to admission.
-Tobacco history:  none
-ETOH:  none
-Illicit drugs:  none 

### Response:
{'Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Pneumonitis due to inhalation of food or vomitus,Cerebral artery occlusion, unspecified with cerebral infarction,Encephalopathy, unspecified,Other pulmonary insufficiency, not elsewhere classified,Malignant essential hypertension,Coronary atherosclerosis of native coronary artery,Hypoxemia,Unspecified persistent mental disorders due to conditions classified elsewhere,Other chronic pulmonary heart diseases,Other iatrogenic hypotension,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Nonspecific abnormal findings in stool contents,Anemia, unspecified,Family history of ischemic heart disease,Dermatophytosis of the body,Arthropathy, unspecified, site unspecified'}
