CHIEF COMPLAINT: hypoxic respiratory distress

PRESENT ILLNESS: This is an 80 yo F with dementia, mental retardation, diastolic
CHF, restrictive lung disease, recurrent pnas, h/o intubation,
anemia, who presents with hypoxic respiratory distress.  Pt was
found to be in acute respiratory distress at her [**Hospital3 **]
facility with O2 sats in the 40s. Apparently the pt had been
noted to have severe lethary and wheezing at her [**Hospital 4382**].  She was placed on 100%NRB at her facility and was then
brought to ED.
.
In [**Name (NI) **], pt was found to be satting at 46%on RA and 91-100%NRB,
T98.5, HR 90, BP 165/76, RR22.  She appeared to be in
respiratory distress with dusky cyanotic hands.  Pt was
confused, disoriented, agitated and was placed in restraints.
She was given A/A nebs, solumedrol, levofloxacin 500 mg IV x1,
Vancomycin 1gm IV x1.  Initial ABG revealed: 7.34/72/96 on 100%
NRB.  She had a WBC of 14 with 92%PMN.  CXR revealed RLL
atelectasis vs infiltrate.

MEDICAL HISTORY: -dementia
-mild mental retardation
-Diastolic CHF
-HTN
-SVT
-Restrictive lung dz
-Mult PNAs
-GERD
-diverticulosis
-DJD lower spine
-Osteoporosis
-Arthritis, left hand contracture
-Urinary/fecal incontinence
-Mult UTIs--indwelling foley
-CRI, bl Cr 0.8-1.1
-Anemia, bl HCT 28
-Depression
-hard of hearing, deafness in left ear
-headaches
-Hip surgery
-breast surgery involving with removal of calcium deposits
.
Cardiology Report ECHO Study Date of [**2110-8-19**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal

MEDICATION ON ADMISSION: --Tylenol prn
--SQ Heparin
--Protonix 40'
--Dilt HCL 120 SR qd
--ASA 81
--Atorvastatin 10'
--Cholecalciferol 400 '
--Lexapro 10 qd
--Tums 500 qd
--MV
--Atrovent neb q6hr
--Lasix 20 mg po qd
--Trazadone 25 mg qhs prn

ALLERGIES: Verapamil / Levaquin

PHYSICAL EXAM: Vitals: T 98.4 BP 165/65 HR 86 RR 25 Sat 83-86% 4LNC
Gen: pleasant elderly woman, in mild resp distress with
accessory muscle use,  able to speak in partial sentences, often
smiling
HEENT: EOMI, PERRL, OP clear with poor dentition
Neck: no LAD, JVP elevated to jaw on R but difficult to assess
due to accessory muscle use
CVS: RRR, nl s1 s2, 2/6 systolic murmur at RUSB
Chest: lungs CTA anteriorly
Abd: soft, NT/ND, NABS
Ext: no tenderness, no LE edema
Neuro: MAFE

FAMILY HISTORY: Father--died of PE
Brother--died of lung CA

SOCIAL HISTORY: Lives at [**Hospital2 **] [**Hospital3 **] [**Telephone/Fax (1) 70302**].  Health care
proxy [**Name (NI) **] [**Name (NI) **] (w)[**Telephone/Fax (1) 104838**], cell [**Telephone/Fax (1) 104839**].
Wheelchair bound due to arthritis.   The patient was never a
smoker, does not drink alcohol. The patient obtains no exercise.
Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Atrial flutter,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Unspecified essential hypertension,Mild intellectual disabilities,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,Esophageal reflux
Food/vomit pneumonitis,Acute & chronc resp fail,Ac on chr diast hrt fail,Atrial flutter,Acidosis,Acute kidney failure NOS,Chronic kidney dis NOS,Hypertension NOS,Mild intellect disabilty,Mental disor NEC oth dis,Osteoporosis NOS,Esophageal reflux
Admission Date:  [**2110-12-31**]              Discharge Date:   [**2111-1-13**]

Date of Birth:  [**2030-6-1**]             Sex:   F

Service: MEDICINE

Allergies:
Verapamil / Levaquin

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hypoxic respiratory distress

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is an 80 yo F with dementia, mental retardation, diastolic
CHF, restrictive lung disease, recurrent pnas, h/o intubation,
anemia, who presents with hypoxic respiratory distress.  Pt was
found to be in acute respiratory distress at her [**Hospital3 **]
facility with O2 sats in the 40s. Apparently the pt had been
noted to have severe lethary and wheezing at her [**Hospital 4382**].  She was placed on 100%NRB at her facility and was then
brought to ED.
.
In [**Name (NI) **], pt was found to be satting at 46%on RA and 91-100%NRB,
T98.5, HR 90, BP 165/76, RR22.  She appeared to be in
respiratory distress with dusky cyanotic hands.  Pt was
confused, disoriented, agitated and was placed in restraints.
She was given A/A nebs, solumedrol, levofloxacin 500 mg IV x1,
Vancomycin 1gm IV x1.  Initial ABG revealed: 7.34/72/96 on 100%
NRB.  She had a WBC of 14 with 92%PMN.  CXR revealed RLL
atelectasis vs infiltrate.


Past Medical History:
-dementia
-mild mental retardation
-Diastolic CHF
-HTN
-SVT
-Restrictive lung dz
-Mult PNAs
-GERD
-diverticulosis
-DJD lower spine
-Osteoporosis
-Arthritis, left hand contracture
-Urinary/fecal incontinence
-Mult UTIs--indwelling foley
-CRI, bl Cr 0.8-1.1
-Anemia, bl HCT 28
-Depression
-hard of hearing, deafness in left ear
-headaches
-Hip surgery
-breast surgery involving with removal of calcium deposits
.
Cardiology Report ECHO Study Date of [**2110-8-19**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal

with good leaflet excursion and no aortic regurgitation. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Compared with the prior study (tape reviewed) of [**2109-3-22**], the
findings are similar.
.
Spirometry [**2108-12-31**]:
FVC 49% pred, 0.61; FEVQ 82% pred, 0.61; FEV1/FVC 169%pred


Social History:
Lives at [**Hospital2 **] [**Hospital3 **] [**Telephone/Fax (1) 70302**].  Health care
proxy [**Name (NI) **] [**Name (NI) **] (w)[**Telephone/Fax (1) 104838**], cell [**Telephone/Fax (1) 104839**].
Wheelchair bound due to arthritis.   The patient was never a
smoker, does not drink alcohol. The patient obtains no exercise.



Family History:
Father--died of PE
Brother--died of lung CA


Physical Exam:
Vitals: T 98.4 BP 165/65 HR 86 RR 25 Sat 83-86% 4LNC
Gen: pleasant elderly woman, in mild resp distress with
accessory muscle use,  able to speak in partial sentences, often
smiling
HEENT: EOMI, PERRL, OP clear with poor dentition
Neck: no LAD, JVP elevated to jaw on R but difficult to assess
due to accessory muscle use
CVS: RRR, nl s1 s2, 2/6 systolic murmur at RUSB
Chest: lungs CTA anteriorly
Abd: soft, NT/ND, NABS
Ext: no tenderness, no LE edema
Neuro: MAFE


Pertinent Results:
[**2110-12-31**] 09:11PM   TYPE-ART PO2-62* PCO2-62* PH-7.33* TOTAL
CO2-34* BASE XS-3 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2110-12-31**] 09:11PM   LACTATE-3.1*
[**2110-12-31**] 09:11PM   O2 SAT-90
[**2110-12-31**] 09:11PM   freeCa-1.13
[**2110-12-31**] 09:07PM   GLUCOSE-151* UREA N-31* CREAT-1.5* SODIUM-144
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-31 ANION GAP-19
[**2110-12-31**] 09:07PM   ALT(SGPT)-21 AST(SGOT)-21 LD(LDH)-226
CK(CPK)-192* ALK PHOS-85 AMYLASE-84 TOT BILI-0.3
[**2110-12-31**] 09:07PM   LIPASE-73*
[**2110-12-31**] 09:07PM   proBNP-5793*
[**2110-12-31**] 09:07PM   CK-MB-3 cTropnT-<0.01
[**2110-12-31**] 09:07PM   ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-4.5
MAGNESIUM-1.7
[**2110-12-31**] 09:07PM   OSMOLAL-304
[**2110-12-31**] 09:07PM   WBC-12.9* RBC-4.00* HGB-11.4* HCT-35.8*
MCV-90 MCH-28.4 MCHC-31.7 RDW-15.4
[**2110-12-31**] 09:07PM   NEUTS-97.8* BANDS-0 LYMPHS-1.5* MONOS-0.4*
EOS-0.1 BASOS-0.2
[**2110-12-31**] 09:07PM   HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2110-12-31**] 09:07PM   PLT SMR-NORMAL PLT COUNT-263
[**2110-12-31**] 09:07PM   PT-13.0 PTT-22.2 INR(PT)-1.1
[**2110-12-31**] 05:45PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2110-12-31**] 05:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2110-12-31**] 03:14PM   TYPE-[**Last Name (un) **] PO2-35* PCO2-76* PH-7.32* TOTAL
CO2-41* BASE XS-8
[**2110-12-31**] 01:30PM   CK(CPK)-179*
[**2110-12-31**] 01:30PM   cTropnT-<0.01
[**2110-12-31**] 01:30PM   CK-MB-3
[**2110-12-31**] 01:30PM   WBC-14.0*# RBC-4.39# HGB-12.6 HCT-38.9 MCV-89
MCH-28.8 MCHC-32.5 RDW-15.6*
[**2110-12-31**] 01:30PM   NEUTS-92.0* LYMPHS-4.3* MONOS-3.1 EOS-0.1
BASOS-0.5
[**2110-12-31**] 01:30PM   HYPOCHROM-1+
[**2110-12-31**] 01:30PM   PLT COUNT-272
[**2110-12-31**] 01:30PM   PT-12.4 PTT-23.1 INR(PT)-1.1
[**2110-12-31**] 01:30PM   D-DIMER-566*
[**2110-12-31**] 12:55PM   TYPE-ART TEMP-36.7 O2-100 PO2-96 PCO2-72*
PH-7.34* TOTAL CO2-41* BASE XS-9 AADO2-558 REQ O2-91
INTUBATED-NOT INTUBA COMMENTS-NRB
.
CXR [**12-31**]:
IMPRESSION: Left basilar atelectasis vs. pneumonia.There is a
right diaphragmatic hernia which extends across the midline to
the
left, unchanged from [**2110-8-20**].  There is linear
atelectasis at the right base.
.
EKG: NSR, nl axis, biphasic T in precordial leads, Q in lead
III, atrial enlargement?


Brief Hospital Course:
On admission to the ICU, the pt was satting in the 80s on both
RA and 4LNC.  Her ABG revealed: 7.33/62/62/34 with A-a gradient
of 95. Pt was started on a 500 cc bolus of NS and then D51/2 at
70 cc/hr. Pts sats dropped back down to 79% on 4LNC.  She was
given combivent neb and suctioned, bringing her O2 sat back up
to 96% on 50%FIO2.  Repeat ABG: 7.31/65/74 with A-a of 135.
Fluids were stopped and stat CXR revealed likely volume
overload.  BNP came back 5793 and pt was given Lasix 20 mg IVx1,
[**12-1**] inch nitropaste, hydral 10 mg po. Her abx were changed from
ceftriaxone/azithro to zosyn given possibility of nosocomial
infxn.  Vancomycin was continued to cover for aspiration PNA.
On the morning after admission, it was decided to again stop
diuresis and start gentle hydration.  It was felt the pt was
initially dry on admission, leading to her hypernatremia, ARF.
She likely became volume overloaded in the setting of the NS
bolus of 500 cc over 1 hr.  Following that fluid bolus, her Na
did improve to 144.  She was restarted on NS at 100 cc/hr for 1
L.  The hydralazine was discontinued and the diltiazem was
continued to maximize filling time.  She was then discharged to
the floor and was intermittantly hypoxic on RA with sats between
88 - 95%. Therefore she needs rehab for pulmonary toilet.
.
# Hypoxic Resp Distress/Hypercarbic Respiratory
Distress/Respiratory acidosis:  Ddx on admission--noscomial PNA,
aspiration pna, CHF, PE, ?contribution from chronic lung dx.
Leading dx is probably combination of aspiration and CHF.  Pt
admitted with radiologic signs of a PNA.  She was treated with
Levofloxacin, Vanc, and Solumedrol in the ED.  D dimer elevated
to 556, however pt with stable hemodynamics and no other
evidence of PE.  Pts volume status is unclear by PE, however BNP
elevation to 5793 assists in dx of CHF.  A-a gradient of 95, up
to 135 after volume overload. Ruled out for an MI.  We continued
empiric treatment for nosocomial and asp PNA with Zosyn; add
Vanc 1gm IV q48 hr given likely asp PNA. Diltiazem was continued
for rate control to improve diastolic dysfunction.  She was
given A/A nebs prn.  On the night of admission the pt satted
upper 80s-90s on 50%VM.
The pt developed hypercarbic resp distress and was intubated the
am of [**1-2**]. Pt developed hypercarbia on [**1-2**] with delta MS and
with ABG of 7.13/105/81 on 50% face tent.  Pt was intubated in
the morniing and placed on AC. It was unclear if the hypercarbia
was due to MS changes or an aspiration or volume overload event.
 She was extubated [**1-5**] and reintubated the same day for hypoxic
resp distress (sat 80% NRB) unresponsive to nitropaste and
Lasix.  Again, the etiology of the hypoxia was unclear, but was
felt to be due to laryngeal edema given she had no leak on trach
collar.  The pt was started on prednisone 40 mg po qd on [**1-5**].
She successfully was weaned to PS on [**1-6**] with spontaneous
breathing trials on [**1-6**] and [**1-7**] lasting 3 hrs at a time. She
finished her 10 day course of Zosyn and vanc. She needs rehab
for pulmonary toilet, as the last time she had an aspiration
event, she required weeks to be weaned from O2.
.
#Delta MS:  The pt was noted to have an altered MS the am of [**1-2**]
when she was having the episode of hypercarbic respiratory
distress.  It is unclear if the pts delta MS caused her
hypercarbic respiratory distress or vice versa.  Pt was noted
the am [**1-2**] to have intermittent myoclonic activity, however able
to follow commands making seizure unlikely.  Neuro felt pt has
polymyoclonus which is stimulus dependent.  There was concern
for meningitis given ?nuchal rigidity by neuro consult exam,
however there is no evidence of this today.  Head CT is negative
for acute process.
.
#ARF:  Pts BL Cr is 0.8-1.1.  Cr up to 1.6 on admission. Suspect
prerenal etiology given elevated BUN/Cr ratio and Na 147. As per
below under "pump", the pt was initially rapidly hydrated with
500 ccNS resulted in flash pulmonary edema.  She was restarted
on gentle hydration the am after admission.  The pts Creatinine
was noted to rise to 1.6 on [**1-1**] and her UO dropped over the
night into [**1-2**].  She was intially given several NS boluses and
then was given Lasix 20 mg IVx1.  Her UO then improved.  It was
felt the pt had a delicate fluid balance given her diastolic
dysfunction and will likely need intermittent hydration with
lasix to optimize forward flow. The  pts Cr improved to 1.4 with
lasix and hydration, however it never returned to her original
baseline.  The pt likely has a new baseline Cr level of 1.3-1.5.
.
#Elevated Na: Na 147 on admission.  Pt appeared volume depleted.
Pt desatted after intial fluid bolus but Na did improve to 144.
The morning after admission the pt was started on slow rate of
NS given episode of hypoxia s/p NS bolus.  Dilt was continued to
maximize rate control and CO. The pts Na ultimately normalized
after free water boluses.
.
#Elevated lactate: Lactate 3.2 on night of admission up from 1.2
in ED.  Likely due to hypoperfusion in the setting of CHF.
Following fluid resusciation the pts lactate levels normalized.
.
#CV:
A Pump: Pt has h/o diastolic dysfunction,nl EF. Initial CXR did
not show clear signs of volume overload, but second CXR was c/w
volume overload.  The pt likely flashed from rapid fluid
infusion.  However, it was felt the pt was dry given her
clinical exam, ARF, and hypernatremia.  The goal was to ideally
decrease HR for increased filling time and give gentle hydration
to increase CO.  The pts diltiazem SR was changed to a QID
regimen.  She was intially given 500cc NS on the night of
admission, however backflashed her fluids.  She was given hydral
10 mg po x1, nitropaste, Lasix 20 mg IVx 1 and then 40 mg IVx1
over the night of admission.  On the morning after admission it
was decided to restart gentle fluids to improve her CO.  The pt
was given several fluid boluses on [**1-1**] and then 20 mg IV lasix
later that night due to decreased UO. Dilt gtt was started on
[**1-2**] to optimize filling time.  It was felt the pt had a delicate
fluid balance given her diastolic dysfunction and would likely
need intermittent hydration with lasix to optimize forward flow.
TTE on [**1-2**] revealed nl systolic function with EF 55%, increased
E:A ratio indicative of diastolic dysfunction, and no LVH. The
pts dilt gtt was turned off the following day and was was
restarted on dilt 45 mg po TID.  Her fluid balance was mostly
determined by her UO; she received intermittent fluids and
Lasix.

# Atrial fultter: while on the floor, the patient developed
atrial flutter with variable rate of conduction. Her BP was
stable the entire time and she was given IV dilt, which
converted her. Her dilt xr was increased to 180. She needs the
lowest heart rate she can tolerated given her distolic
dysfunction.
.
# Aspiration: The patient has a known aspiration risk. She has
had multiple admission for this inthe past, and the initial
insult to prompt this admission was an aspiration event. The
team as recommended that she be NPO and communicated this to the
neice, however, since eating is her main enjoyment, her neice
would like her to continue eating. She remains full code. This
needs to be addresed by her PCP with the [**Name9 (PRE) 21457**] again, since she
will likley continue to have recurrent aspiration pneumonias if
she continues to eat.

Medications on Admission:
--Tylenol prn
--SQ Heparin
--Protonix 40'
--Dilt HCL 120 SR qd
--ASA 81
--Atorvastatin 10'
--Cholecalciferol 400 '
--Lexapro 10 qd
--Tums 500 qd
--MV
--Atrovent neb q6hr
--Lasix 20 mg po qd
--Trazadone 25 mg qhs prn


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
7. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
once a day.
9. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Atrovent 0.02 % Solution Sig: One (1)  Inhalation every six
(6) hours: atrovent neb q6 please.
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
aspiration PNA
mental retardation
diastolic dysfunction and heart failure


Discharge Condition:
good, 95% on RA. feeding self with help.

Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L
Return to the ED if you have O2 sat < 90% or HR > 120

Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) **] on Wednesday [**1-26**] at
8:30AM
{'Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Atrial flutter,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Unspecified essential hypertension,Mild intellectual disabilities,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,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: hypoxic respiratory distress

PRESENT ILLNESS: This is an 80 yo F with dementia, mental retardation, diastolic
CHF, restrictive lung disease, recurrent pnas, h/o intubation,
anemia, who presents with hypoxic respiratory distress.  Pt was
found to be in acute respiratory distress at her [**Hospital3 **]
facility with O2 sats in the 40s. Apparently the pt had been
noted to have severe lethary and wheezing at her [**Hospital 4382**].  She was placed on 100%NRB at her facility and was then
brought to ED.
.
In [**Name (NI) **], pt was found to be satting at 46%on RA and 91-100%NRB,
T98.5, HR 90, BP 165/76, RR22.  She appeared to be in
respiratory distress with dusky cyanotic hands.  Pt was
confused, disoriented, agitated and was placed in restraints.
She was given A/A nebs, solumedrol, levofloxacin 500 mg IV x1,
Vancomycin 1gm IV x1.  Initial ABG revealed: 7.34/72/96 on 100%
NRB.  She had a WBC of 14 with 92%PMN.  CXR revealed RLL
atelectasis vs infiltrate.

MEDICAL HISTORY: -dementia
-mild mental retardation
-Diastolic CHF
-HTN
-SVT
-Restrictive lung dz
-Mult PNAs
-GERD
-diverticulosis
-DJD lower spine
-Osteoporosis
-Arthritis, left hand contracture
-Urinary/fecal incontinence
-Mult UTIs--indwelling foley
-CRI, bl Cr 0.8-1.1
-Anemia, bl HCT 28
-Depression
-hard of hearing, deafness in left ear
-headaches
-Hip surgery
-breast surgery involving with removal of calcium deposits
.
Cardiology Report ECHO Study Date of [**2110-8-19**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) appear structurally normal

MEDICATION ON ADMISSION: --Tylenol prn
--SQ Heparin
--Protonix 40'
--Dilt HCL 120 SR qd
--ASA 81
--Atorvastatin 10'
--Cholecalciferol 400 '
--Lexapro 10 qd
--Tums 500 qd
--MV
--Atrovent neb q6hr
--Lasix 20 mg po qd
--Trazadone 25 mg qhs prn

ALLERGIES: Verapamil / Levaquin

PHYSICAL EXAM: Vitals: T 98.4 BP 165/65 HR 86 RR 25 Sat 83-86% 4LNC
Gen: pleasant elderly woman, in mild resp distress with
accessory muscle use,  able to speak in partial sentences, often
smiling
HEENT: EOMI, PERRL, OP clear with poor dentition
Neck: no LAD, JVP elevated to jaw on R but difficult to assess
due to accessory muscle use
CVS: RRR, nl s1 s2, 2/6 systolic murmur at RUSB
Chest: lungs CTA anteriorly
Abd: soft, NT/ND, NABS
Ext: no tenderness, no LE edema
Neuro: MAFE

FAMILY HISTORY: Father--died of PE
Brother--died of lung CA

SOCIAL HISTORY: Lives at [**Hospital2 **] [**Hospital3 **] [**Telephone/Fax (1) 70302**].  Health care
proxy [**Name (NI) **] [**Name (NI) **] (w)[**Telephone/Fax (1) 104838**], cell [**Telephone/Fax (1) 104839**].
Wheelchair bound due to arthritis.   The patient was never a
smoker, does not drink alcohol. The patient obtains no exercise. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Atrial flutter,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Unspecified essential hypertension,Mild intellectual disabilities,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,Esophageal reflux'}
