CHIEF COMPLAINT: shortness of breath, CHF exacerberation

PRESENT ILLNESS: 75 yo F with h/o HTN, CHF, DM II, ? h/o prior MI, and lung CA
s/p partial lung resection [**2179**] who presents with worsening
shortness of breath and cough X 1 week along with subjective
fevers. The pt reports that her cough is productive in nature
and began on Monday. Since then, she has had a steadily
increasing sensation of shortness of breath. Further history was
unable to be obtained [**2-22**] respiratory distress.
.
In the ED, initial vitals were T 101, SBP 210s, HR 90s, O2 sat
86% on RA. On exam, she was speaking in full sentences without
overt difficulty. She was given metoprolol 5 mg IV X 2 for her
elevated SBP with worsening of her shortness of breath and the
pt was placed on a [**Month/Day (2) 597**] with O2 sats in the upper 90s. An EKG
showed increased ectopy but otherwise no new dynamic ischemic
changes and a CXR was significant for increased fluid suggestive
of CHF exacerbation and a basilar opacity in the left lower lobe
could not be ruled out for possible pneumonia. She was given 100
IV lasix with 800 ccs urine output over 1 hr, ceftriaxone 1 gm X
1, azithromycin 500 mg X 1, and started on a nitro gtt with
improvement in SBPs down to the 150s. An ABG on either RA or [**Name (NI) 597**]
(unclear from charting) was 7.40/34/57/22. She was then admitted
to the CCU for CHF exacerbation.
.
Of note, the pt was admitted in [**12-25**] with similar symptoms of
cough and shortness breath and was treated for a CHF
exacerbation as well as PNA. She had a TTE performed that showed
a LVEF 45% with septal hypokinesis and RV apical free wall
hypokinesis. A p-MIBI showed no perfusion defects and a LVEF
54%. She was discharged and followed up with Dr. [**Last Name (STitle) **] in [**5-26**]
whose impression was that diastolic heart failure exacerbation
was the etiology of her admission.
.
Further ROS of systems unable to be obtained [**2-22**] respiratory
distress, pt placed on BIPAP.

MEDICAL HISTORY: - HTN
- DM2
- peripheral neuropathy
- h/o lung CA s/p resection
- h/o A.fib
- LE edema/venous stasis
- s/p TAH/BSO
- anxiety
- Anemia - mild renal insuffic, normal iron, b12, folate, retic

MEDICATION ON ADMISSION: ASA 162 mg daily
Hydralazine 50 mg tid
Isosorbide Mononitrate 120 mg daily
Lasix 80 mg daily
Metoprolol 50 mg [**Hospital1 **]
Pravastatin 40 mg daily
Coumadin 5 mg daily
Trazodone 25 mg qhs prn
Ativan 0.5 mg tid prn
Latanoprost 0.005% 1 drop daily
Cosopt 0.5-2% 1 drop R eye [**Hospital1 **]
Glyburide 5 mg tid
Docusate 100 mg [**Hospital1 **] prn
Mineral oil 1 tbsp daily

ALLERGIES: Zestril / Maxaquin / Norvasc / Percocet

PHYSICAL EXAM: VS: T 96.5, BP 141/59, HR 77, RR 29, O2 98% on BIPAP FiO2 100%,
PS 10 PEEP 5
Gen: WDWN elderly female in respiratory distress, improved with
BIPAP. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP distended up to angle of jaw
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were initially labored with accessory muscle use, improved with
initiation of BIPAP. crackles half up lung fields b/l, coarse
upper airway breath sounds
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Venous (peripheral) insufficiency, unspecified,Personal history of malignant neoplasm of bronchus and lung,Old myocardial infarction,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia in chronic kidney disease
Acute respiratry failure,Pneumonia, organism NOS,Ac on chr diast hrt fail,Acute kidney failure NOS,Chronic kidney dis NOS,Dysthymic disorder,Venous insufficiency NOS,Hx-bronchogenic malignan,Old myocardial infarct,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Anemia in chr kidney dis
Admission Date:  [**2188-12-13**]              Discharge Date:   [**2188-12-23**]

Date of Birth:  [**2113-5-27**]             Sex:   F

Service: MEDICINE

Allergies:
Zestril / Maxaquin / Norvasc / Percocet

Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
shortness of breath, CHF exacerberation

Major Surgical or Invasive Procedure:
Intubation/Extubation


History of Present Illness:
75 yo F with h/o HTN, CHF, DM II, ? h/o prior MI, and lung CA
s/p partial lung resection [**2179**] who presents with worsening
shortness of breath and cough X 1 week along with subjective
fevers. The pt reports that her cough is productive in nature
and began on Monday. Since then, she has had a steadily
increasing sensation of shortness of breath. Further history was
unable to be obtained [**2-22**] respiratory distress.
.
In the ED, initial vitals were T 101, SBP 210s, HR 90s, O2 sat
86% on RA. On exam, she was speaking in full sentences without
overt difficulty. She was given metoprolol 5 mg IV X 2 for her
elevated SBP with worsening of her shortness of breath and the
pt was placed on a [**Month/Day (2) 597**] with O2 sats in the upper 90s. An EKG
showed increased ectopy but otherwise no new dynamic ischemic
changes and a CXR was significant for increased fluid suggestive
of CHF exacerbation and a basilar opacity in the left lower lobe
could not be ruled out for possible pneumonia. She was given 100
IV lasix with 800 ccs urine output over 1 hr, ceftriaxone 1 gm X
1, azithromycin 500 mg X 1, and started on a nitro gtt with
improvement in SBPs down to the 150s. An ABG on either RA or [**Name (NI) 597**]
(unclear from charting) was 7.40/34/57/22. She was then admitted
to the CCU for CHF exacerbation.
.
Of note, the pt was admitted in [**12-25**] with similar symptoms of
cough and shortness breath and was treated for a CHF
exacerbation as well as PNA. She had a TTE performed that showed
a LVEF 45% with septal hypokinesis and RV apical free wall
hypokinesis. A p-MIBI showed no perfusion defects and a LVEF
54%. She was discharged and followed up with Dr. [**Last Name (STitle) **] in [**5-26**]
whose impression was that diastolic heart failure exacerbation
was the etiology of her admission.
.
Further ROS of systems unable to be obtained [**2-22**] respiratory
distress, pt placed on BIPAP.


Past Medical History:
- HTN
- DM2
- peripheral neuropathy
- h/o lung CA s/p resection
- h/o A.fib
- LE edema/venous stasis
- s/p TAH/BSO
- anxiety
- Anemia - mild renal insuffic, normal iron, b12, folate, retic

- chronic urticaria/hives
.
Cardiac Risk Factors: Diabetes, Hypertension
.
Cardiac History: no prior CABG, PCI, or PPM


Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.


Family History:
Non-contributory

Physical Exam:
VS: T 96.5, BP 141/59, HR 77, RR 29, O2 98% on BIPAP FiO2 100%,
PS 10 PEEP 5
Gen: WDWN elderly female in respiratory distress, improved with
BIPAP. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP distended up to angle of jaw
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were initially labored with accessory muscle use, improved with
initiation of BIPAP. crackles half up lung fields b/l, coarse
upper airway breath sounds
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP



Pertinent Results:
Labs:

[**2188-12-13**] 01:00AM BLOOD WBC-11.3* RBC-3.61* Hgb-10.4* Hct-30.1*
MCV-83 MCH-28.7 MCHC-34.4 RDW-15.1 Plt Ct-271
[**2188-12-14**] 05:13AM BLOOD WBC-10.3 RBC-2.89* Hgb-8.3* Hct-24.7*
MCV-86 MCH-28.7 MCHC-33.6 RDW-15.1 Plt Ct-222
[**2188-12-15**] 05:09AM BLOOD WBC-9.1 RBC-3.28* Hgb-9.4* Hct-27.1*
MCV-83 MCH-28.8 MCHC-34.9 RDW-15.1 Plt Ct-177
[**2188-12-16**] 02:34AM BLOOD WBC-9.4 RBC-3.35* Hgb-9.5* Hct-27.9*
MCV-83 MCH-28.2 MCHC-33.9 RDW-15.2 Plt Ct-186
[**2188-12-17**] 05:14AM BLOOD WBC-13.0* RBC-4.17* Hgb-11.9*# Hct-35.5*
MCV-85 MCH-28.4 MCHC-33.4 RDW-15.2 Plt Ct-307#
[**2188-12-17**] 04:20PM BLOOD WBC-10.4 RBC-3.83* Hgb-10.7* Hct-32.0*
MCV-84 MCH-28.1 MCHC-33.6 RDW-15.0 Plt Ct-261
[**2188-12-19**] 06:41AM BLOOD WBC-10.8 RBC-3.51* Hgb-10.0* Hct-30.0*
MCV-85 MCH-28.6 MCHC-33.5 RDW-15.1 Plt Ct-270
[**2188-12-20**] 07:01AM BLOOD WBC-7.1 RBC-3.32* Hgb-9.4* Hct-28.0*
MCV-84 MCH-28.4 MCHC-33.7 RDW-15.2 Plt Ct-213
[**2188-12-21**] 07:02AM BLOOD WBC-6.7 RBC-3.12* Hgb-8.9* Hct-26.9*
MCV-86 MCH-28.4 MCHC-33.1 RDW-15.1 Plt Ct-225
[**2188-12-22**] 07:15AM BLOOD WBC-6.3 RBC-3.08* Hgb-8.8* Hct-26.8*
MCV-87 MCH-28.4 MCHC-32.6 RDW-15.4 Plt Ct-290
[**2188-12-13**] 01:00AM BLOOD Neuts-79.4* Lymphs-13.3* Monos-5.3
Eos-1.9 Baso-0.2
[**2188-12-16**] 02:34AM BLOOD Neuts-86.9* Lymphs-8.2* Monos-3.6 Eos-1.3
Baso-0.1
[**2188-12-18**] 03:42AM BLOOD Neuts-86.5* Lymphs-6.9* Monos-5.0 Eos-1.5
Baso-0.1
[**2188-12-19**] 06:41AM BLOOD Neuts-78.3* Lymphs-12.0* Monos-5.1
Eos-4.5* Baso-0.1
[**2188-12-20**] 07:01AM BLOOD Neuts-77.0* Lymphs-13.6* Monos-5.3
Eos-4.1* Baso-0.1
[**2188-12-13**] 01:00AM BLOOD PT-36.6* PTT-37.7* INR(PT)-3.9*
[**2188-12-14**] 05:34AM BLOOD PT-31.3* PTT-54.3* INR(PT)-3.2*
[**2188-12-15**] 05:09AM BLOOD PT-30.7* PTT-53.3* INR(PT)-3.2*
[**2188-12-16**] 02:34AM BLOOD PT-26.2* PTT-40.0* INR(PT)-2.6*
[**2188-12-17**] 05:14AM BLOOD PT-15.9* PTT-29.7 INR(PT)-1.4*
[**2188-12-17**] 06:37PM BLOOD PT-16.9* PTT-50.6* INR(PT)-1.5*
[**2188-12-18**] 03:42AM BLOOD PT-18.7* PTT-59.5* INR(PT)-1.7*
[**2188-12-18**] 01:52PM BLOOD PT-19.0* PTT-78.7* INR(PT)-1.8*
[**2188-12-19**] 06:41AM BLOOD PT-17.7* PTT-75.2* INR(PT)-1.6*
[**2188-12-21**] 07:02AM BLOOD PT-18.9* PTT-150 * INR(PT)-1.8*
[**2188-12-22**] 07:15AM BLOOD PT-17.0* PTT-29.5 INR(PT)-1.5*
[**2188-12-13**] 01:00AM BLOOD Glucose-166* UreaN-35* Creat-1.2* Na-139
K-3.7 Cl-105 HCO3-20* AnGap-18
[**2188-12-13**] 03:24PM BLOOD Glucose-87 UreaN-42* Creat-1.6* Na-142
K-3.6 Cl-106 HCO3-23 AnGap-17
[**2188-12-14**] 05:13AM BLOOD Glucose-153* UreaN-49* Creat-1.8* Na-141
K-4.4 Cl-111* HCO3-20* AnGap-14
[**2188-12-15**] 05:09AM BLOOD Glucose-76 UreaN-58* Creat-1.8* Na-145
K-3.9 Cl-113* HCO3-19* AnGap-17
[**2188-12-16**] 02:34AM BLOOD Glucose-97 UreaN-65* Creat-1.3* Na-143
K-3.9 Cl-115* HCO3-19* AnGap-13
[**2188-12-16**] 04:17PM BLOOD Glucose-179* UreaN-63* Creat-1.4* Na-144
K-3.9 Cl-113* HCO3-20* AnGap-15
[**2188-12-17**] 05:14AM BLOOD Glucose-145* UreaN-56* Creat-1.3* Na-144
K-3.6 Cl-109* HCO3-22 AnGap-17
[**2188-12-18**] 03:42AM BLOOD Glucose-205* UreaN-68* Creat-1.4* Na-143
K-4.4 Cl-112* HCO3-26 AnGap-9
[**2188-12-20**] 07:01AM BLOOD Glucose-156* UreaN-59* Creat-1.8* Na-139
K-4.0 Cl-106 HCO3-19* AnGap-18
[**2188-12-21**] 07:02AM BLOOD Glucose-197* UreaN-60* Creat-1.7* Na-143
K-4.5 Cl-109* HCO3-20* AnGap-19
[**2188-12-22**] 07:15AM BLOOD Glucose-203* UreaN-65* Creat-1.5* Na-141
K-4.3 Cl-109* HCO3-23 AnGap-13
[**2188-12-13**] 01:00AM BLOOD CK(CPK)-136
[**2188-12-13**] 06:06AM BLOOD CK(CPK)-177*
[**2188-12-13**] 03:24PM BLOOD CK(CPK)-270*
[**2188-12-13**] 09:51PM BLOOD CK(CPK)-269*
[**2188-12-14**] 05:13AM BLOOD LD(LDH)-284* CK(CPK)-218* TotBili-0.3
[**2188-12-17**] 05:14AM BLOOD CK(CPK)-107
[**2188-12-17**] 04:20PM BLOOD CK(CPK)-110
[**2188-12-18**] 03:42AM BLOOD CK(CPK)-105
[**2188-12-13**] 01:00AM BLOOD CK-MB-4 proBNP-2879*
[**2188-12-13**] 01:00AM BLOOD cTropnT-0.03*
[**2188-12-13**] 06:06AM BLOOD CK-MB-8 cTropnT-0.18*
[**2188-12-13**] 03:24PM BLOOD CK-MB-10 MB Indx-3.7 cTropnT-0.77*
[**2188-12-13**] 09:51PM BLOOD CK-MB-10 MB Indx-3.7 cTropnT-0.77*
[**2188-12-14**] 05:13AM BLOOD CK-MB-9 cTropnT-0.51*
[**2188-12-17**] 05:14AM BLOOD CK-MB-4 cTropnT-0.39*
[**2188-12-17**] 04:20PM BLOOD CK-MB-5 cTropnT-0.47*
[**2188-12-13**] 06:06AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.2
[**2188-12-13**] 03:24PM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
[**2188-12-13**] 09:51PM BLOOD Albumin-2.8* Calcium-7.9* Phos-4.4 Mg-1.8
[**2188-12-14**] 05:13AM BLOOD Calcium-7.7* Phos-4.6* Mg-1.9
[**2188-12-15**] 05:09AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.2
[**2188-12-16**] 02:34AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.4
[**2188-12-17**] 04:20PM BLOOD Calcium-8.4 Phos-3.6 Mg-2.5
[**2188-12-18**] 03:42AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.4
[**2188-12-19**] 06:41AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.4
[**2188-12-20**] 07:01AM BLOOD Calcium-7.9* Phos-4.9* Mg-2.4
[**2188-12-14**] 05:13AM BLOOD Hapto-264*
[**2188-12-18**] 03:42AM BLOOD TSH-2.4
[**2188-12-14**] 05:13AM BLOOD Cortsol-25.9*
[**2188-12-17**] 07:36AM BLOOD Lactate-1.5
[**2188-12-20**] 07:01AM BLOOD Metanephrines (Plasma)-PND
.
Imaging/Studies:
.
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with chf exacerbation, decreased oxygenation
REASON FOR THIS EXAMINATION:
evaluate for acute change
STUDY: AP chest, [**2188-12-13**].
HISTORY: 75-year-old woman with congestive heart failure and
decreased oxygenation.
FINDINGS: Comparison is made to the previous study from [**12-13**], [**2188**], at 8:54 a.m.
There has been placement of an endotracheal tube whose distal
tip is at the level of the clavicles. Nasogastric tube sideport
is just below the gastroesophageal junction. There remains
bilateral airspace opacities, right side worse than left which
are stable.
.
ECHO [**12-13**]: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is severe
mitral annular calcification. There is moderate thickening of
the mitral valve chordae. At least mild to moderate ([**1-22**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation is probably significantly
UNDERestimated.] The pulmonary artery systolic pressure could
not be determined. There is a small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2188-1-11**], the left ventricle is now hyperdynamic;
hypokinesis of the interventricular septum and of the right
ventricle is no longer seen.
IMPRESSION: hyperdynamic left ventricle
.
[**12-15**]: CT Abd/Pelvis:
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. Bibasilar opacities in the lungs suggestive of pneumonia
and/or aspiration with associated small simple pleural
effusions.
.
CXR [**12-15**]:IMPRESSION: Continued improvement in pulmonary edema
particularly in the right upper lobe. Left pleural effusion with
atelectasis persists though underlying pneumonia cannot be
excluded.
.
CXR [**12-17**]: IMPRESSION: After extubation, patient has redeveloped
moderate-to-severe pulmonary edema with predominance in the
right upper lobe, which raises the question whether the patient
has mitral regurgitation. There is some increase in small left
pleural effusion and atelectasis and probable small right
pleural effusion.
.
Renal US: IMPRESSION:
1. Normal Doppler examination of the kidneys, with no
son[**Name (NI) 493**] evidence of renal artery stenosis.
2. Simple cyst of the right kidney.
.
CXR [**12-19**]: IMPRESSION: Unchanged moderate asymmetric pulmonary
edema with left greater than right small pleural effusions. Left
retrocardiac opacity likely represents pleural effusion with
atelectasis although consolidation cannot be excluded. Overall
unchanged from one day prior.
.
CXR [**12-21**]: IMPRESSION:
1. Interval improvement in right upper lobe pneumonia with mild
decrease in consolidation.
2. Continued left lower lobe consolidation with small left
pleural effusion. Cardiomegaly.
.
C. Diff toxin: Negative x1
.
BCX: All no growth
.
Direct Influenza A and B antigen: Negative
.
Legionella Urinary Antigen: Negative




Brief Hospital Course:
# Hypertensive urgency: The patient presented with systolic
blood pressures in the 200s.  At the time, the patient developed
flash pulmonary edema leading to decreased oxygen saturation to
the 80s and significant respiratory distress.  This required
BiPAP which initially increased her O2 sats, and then intubation
during the first day of her admission due to inability to
tolerate less invasive methods.  She subsequently developed
several other episodes of anxiety after extubation complicated
by systolic blood pressures in the 200s with flash pulmonary
edema. She intermittently required a nitro gtt for control of
her blood pressures. Renal ultrasound was negative for renal
artery stenosis. Additionally, urinary metanephrines were sent
for work up of pheochromocytoma to evaluate for secondary causes
of hypertension. This was pending at the time of discharge. TSH
was within normal limits as well. Unclear if the patient's
hypertensive episodes are entirely secondary to anxiety and
agitation or if there is another cause.  The patient's
hypertensive regimen was increased and she is discharged on new
doses of hydral and imdur. She should follow up with her
outpatient physician for further management of her hypertension.

.
#) Respiratory failure/Multifocal pneumonia: As above, patient
was admitted with significant pulmonary edema, known diastolic
CHF as well as a multifocal pneumonia. She was treated for
community acquired pneumonia with 5 days of azithromycin and 7
days of ceftriaxone. Additionally, she was diuresed with
clinical improvement.  She continues to improve both clinically
and radiographically. All blood cultures during admission were
negative.
.
#) Cardiac
-Ischemia: Patient with transient ischemic changes on ECG during
her hypertensive episodes. Troponins were slightly elevated at
0.03 with no change in CK. No history of cardiac cath, though no
ischemic changes on p-MIBI in 12.06. Patient should have
outpatient follow up for evaluation of coronary artery disease.
She should continue on aspirin, atorvastatin and carvedilol as
above.
-Pump: Prior history of diastolic dysfunction with LVEF 54% on
p-MIBI in [**12-25**]. ECHO on [**12-13**] showing hyperdynamic left
ventricle.  Patient was continued on hydralazine and Isordil
with up-titration for tighter blood pressure control.
Additionally, she was aggressively diuresed in the setting of
significant pulmonary edema during her admission.  She is
currently on standing Lasix 40mg PO daily. This can be further
adjusted based on her fluid status as an outpatient.
-Rhythm: History of paroxysmal atrial fibrillation. Currently in
sinus rhythm.  INR was supratherapeutic at 3.9 on admission.
Coumadin initially held then started on heparin gtt. On coumadin
with INR of 1.7 on discharge [**12-23**]. Please continue coumadin and
increase dose if INR not therapeutic, next INR check on [**12-26**].
Bradycardia to 40s, sinus, asymptomatic with pauses of up to 3.9
seconds.  Please check EKG within 2 days of discharge and if
symptomatic bradycardia decrease lopressor dose (now 50mg po
bid)
.
#) Anemia: Baseline as per OMR appears to be Hct of 28-30 with
normal MCV.  Hematocrit was 30 on admission.  Hct initially
decreased over two days to 23. She received 3 units of pRBCs
with an appropriate bump in her hematocrit.  Guaiac and NG
aspirate were negative. CT of abdomen and pelvis were negative
for RP or other source of bleeding.  Hematocrit continued to
remain stable for the duration of admission. Prior iron studies
within normal limits.  Will likely need work up as an
outpatient.
.
#) Agitation/anxiety: Per the patient and her family, she has
significant anxiety at home. She states she takes lorazepam 1mg
daily at home with occasional prn doses as needed.  Here, during
an episode of significant anxiety, patient was given 1mg IV
ativan and became significantly more agitated.  Geriatrics
consult recommended oxazepam 15mg qhs with once daily prn dosing
for anxiety attacks. Additionally, patient was started on
sertraline 25mg qhs, to be increased on 50mg qhs on [**2188-12-29**].
She should continue breathing and visualization exercises prior
to taking pm medications.  She can follow up in the Geriatric
[**Hospital **] Clinic for further management of her depression and
anxiety symptoms.
.
#) DM II: Initially, Glyburide was held in the setting of
intubation with decreased POs and mild ARF.  She was placed on
an insulin sliding scale initially.  Glyburide restarted at
2.5mg daily prior to discharge. As POs and renal function become
normalized, this can be increased to her home regimen of 5mg po
daily of glyburide. HgbA1c 6.6 in [**9-26**].
.
#) Renal Insufficiency: Baseline Cr 1.3 - 1.5, Cr on admission
1.2.  Her creatinine increased to 1.9 on her first day of
admission, but has returned to baseline at the time of discharge
(discharge INR 1.5 on [**12-23**]). Urine eosinophils negative.
.
#) Code - FULL


Medications on Admission:
ASA 162 mg daily
Hydralazine 50 mg tid
Isosorbide Mononitrate 120 mg daily
Lasix 80 mg daily
Metoprolol 50 mg [**Hospital1 **]
Pravastatin 40 mg daily
Coumadin 5 mg daily
Trazodone 25 mg qhs prn
Ativan 0.5 mg tid prn
Latanoprost 0.005% 1 drop daily
Cosopt 0.5-2% 1 drop R eye [**Hospital1 **]
Glyburide 5 mg tid
Docusate 100 mg [**Hospital1 **] prn
Mineral oil 1 tbsp daily


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
Disp:*360 Tablet(s)* Refills:*0*
6. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
7. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily)
as needed.
Disp:*15 Capsule(s)* Refills:*0*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO As directed:
Take half tablet daily until [**2188-12-29**]. Then take one tablet
daily at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED): humalog sliding scale, 2 units
sc insulin qac and qhs, scale to begin at blood glucose of 150
and increase by 2 units insulin for ever 50 points increase in
blood glucose above 150.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
15. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: give with 120mg
tablet of imdur.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]

Discharge Diagnosis:
CHF exacerbation
Multifocal community acquired pneumonia
.
Secondary diagnoses:
Normocytic anemia
Type II DM
Hypertension
Anxiety
Depression


Discharge Condition:
Stable


Discharge Instructions:
If you develop shortness of breath, increased cough, dizziness,
changes in vision, chest pain, severe headache or any other
changes that concern you, you should go to the nearest Emergency
Room or call your primary care doctor as soon as possible.
.
We have made a number of changes to your medications. These
include:
1. Serax (Oxazepam) has taken the place of Lorazepam. Please
take this medication as directed.
2. Zoloft (Sertraline) has been started. You should take this as
directed.
3. Your Hydralazine has been changed to 75mg four times a day.
4. Metoprolol 50mg twice daily
5. Your imdur has been switched to isordil.
.
It is very important that you continue to do your breathing and
visualization exercises to improve your anxiety.  Please take
all your medications and keep your follow up appointments.

Followup Instructions:
Please keep the following appointments:
.
Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2189-2-16**] 9:10
Provider: [**Name10 (NameIs) **] IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-2-19**] 8:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2189-2-19**] 8:50
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Venous (peripheral) insufficiency, unspecified,Personal history of malignant neoplasm of bronchus and lung,Old myocardial infarction,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia in chronic kidney disease'}


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, CHF exacerberation

PRESENT ILLNESS: 75 yo F with h/o HTN, CHF, DM II, ? h/o prior MI, and lung CA
s/p partial lung resection [**2179**] who presents with worsening
shortness of breath and cough X 1 week along with subjective
fevers. The pt reports that her cough is productive in nature
and began on Monday. Since then, she has had a steadily
increasing sensation of shortness of breath. Further history was
unable to be obtained [**2-22**] respiratory distress.
.
In the ED, initial vitals were T 101, SBP 210s, HR 90s, O2 sat
86% on RA. On exam, she was speaking in full sentences without
overt difficulty. She was given metoprolol 5 mg IV X 2 for her
elevated SBP with worsening of her shortness of breath and the
pt was placed on a [**Month/Day (2) 597**] with O2 sats in the upper 90s. An EKG
showed increased ectopy but otherwise no new dynamic ischemic
changes and a CXR was significant for increased fluid suggestive
of CHF exacerbation and a basilar opacity in the left lower lobe
could not be ruled out for possible pneumonia. She was given 100
IV lasix with 800 ccs urine output over 1 hr, ceftriaxone 1 gm X
1, azithromycin 500 mg X 1, and started on a nitro gtt with
improvement in SBPs down to the 150s. An ABG on either RA or [**Name (NI) 597**]
(unclear from charting) was 7.40/34/57/22. She was then admitted
to the CCU for CHF exacerbation.
.
Of note, the pt was admitted in [**12-25**] with similar symptoms of
cough and shortness breath and was treated for a CHF
exacerbation as well as PNA. She had a TTE performed that showed
a LVEF 45% with septal hypokinesis and RV apical free wall
hypokinesis. A p-MIBI showed no perfusion defects and a LVEF
54%. She was discharged and followed up with Dr. [**Last Name (STitle) **] in [**5-26**]
whose impression was that diastolic heart failure exacerbation
was the etiology of her admission.
.
Further ROS of systems unable to be obtained [**2-22**] respiratory
distress, pt placed on BIPAP.

MEDICAL HISTORY: - HTN
- DM2
- peripheral neuropathy
- h/o lung CA s/p resection
- h/o A.fib
- LE edema/venous stasis
- s/p TAH/BSO
- anxiety
- Anemia - mild renal insuffic, normal iron, b12, folate, retic

MEDICATION ON ADMISSION: ASA 162 mg daily
Hydralazine 50 mg tid
Isosorbide Mononitrate 120 mg daily
Lasix 80 mg daily
Metoprolol 50 mg [**Hospital1 **]
Pravastatin 40 mg daily
Coumadin 5 mg daily
Trazodone 25 mg qhs prn
Ativan 0.5 mg tid prn
Latanoprost 0.005% 1 drop daily
Cosopt 0.5-2% 1 drop R eye [**Hospital1 **]
Glyburide 5 mg tid
Docusate 100 mg [**Hospital1 **] prn
Mineral oil 1 tbsp daily

ALLERGIES: Zestril / Maxaquin / Norvasc / Percocet

PHYSICAL EXAM: VS: T 96.5, BP 141/59, HR 77, RR 29, O2 98% on BIPAP FiO2 100%,
PS 10 PEEP 5
Gen: WDWN elderly female in respiratory distress, improved with
BIPAP. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP distended up to angle of jaw
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3, no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were initially labored with accessory muscle use, improved with
initiation of BIPAP. crackles half up lung fields b/l, coarse
upper airway breath sounds
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death. 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Venous (peripheral) insufficiency, unspecified,Personal history of malignant neoplasm of bronchus and lung,Old myocardial infarction,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Anemia in chronic kidney disease'}
