CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 77 y/o F PMH significant CAD s/p several stents, DM,
hyperlipidemia, HTN who presents with shortness of breath of 2
days duration. Patient reports difficulty breathing at rest and
with exertion. She denies any associated chest pain. She reports
baseline ankle edema. She denies orthopenia and PND. She denies
any chest pain or SOB since her cath in [**Month (only) **]. She denies
sick contacts, fevers, [**Name2 (NI) **], increased sputum production, sore
throat and muscle aches. She reports nausea and episode of soft
stool yesterday. She denies bloody or black stool.
.
Patient presented to [**Location (un) 620**] ED - reported to be hypoxic with
improvement on NC. Initial vitals T 100.3, Tm 100.8, P 107, RR
20, Bp 137/62, O2Sat 87% RA. Concern for PNA based on CXR and
given Ceftriaxone/Azithromycin. Per report no EKG changes and
given 4 baby aspirin. Troponin elevated 0.28 consequently
transferred to [**Hospital1 18**] for further management. On arrival to
[**Location (un) 86**] [**Hospital1 18**] T 96.9, BP 124/63, HR 82, RR 18, 97% 4L. Patient
normotensive. O2 sat 97-98% 2-3L. Nitro drip started. Ordered
for 1 pRBC but not hung prior to transfer. Guaiac negative.
.
Patient had recent admission [**Date range (1) **] for NSTEMI s/p DES to
LM, LAD and RCA during the course of two catheterizations.
Metoprolol and Norvasc increased, Hydralazine started. Patient
transfused 2 units for angioseal bleed. CT scan ruled out RP
bleed. Acute on chronic renal failure - felt to be related to
contrast load in cath and required ultrafiltration in CCU.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

MEDICATION ON ADMISSION: Per Needhem Med Rec - patient does not know
- Losartan 50 mgs qd
- Levothyroxine 100 mcg cap
- Hydralazine 50 mg TID
- Imdur 120 mg 24 hour daily
- Lipitor 80 mg tab
- Metformin ER 500 mg qd
- Prilosec 20 mg [**Hospital1 **]
- [**Hospital1 **] 75 mg qd
- Trazadone 75 mgs qhs
- Remeron 30 mg qhs
- Norvasc 10 mg qd
- Metoprolol tartate 150 mgs [**Hospital1 **]
- ASA 81 mg
- Ambien 5 mg
- Lasix 20 mg
- Ritalin 5 mg 1 qam and 1 qpm
- Nitro prn

ALLERGIES: Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult /
Shellfish

PHYSICAL EXAM: GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, jvd to clavicle
RESP: Decreased breath sounds left base. Mild wheezes
throughout. No crackles.
CV: RR, S1 and S2 wnl, 3/6 systolic ejection murmur radiates
throughout.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. 5/5 strength throughout.
RECTAL: Guaiac negative.

FAMILY HISTORY: Mother had CAD and MI. Father died at a young age of MI.

SOCIAL HISTORY: Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.
Other specified forms of effusion, except tuberculous,Acute kidney failure with other specified pathological lesion in kidney,Chronic diastolic heart failure,Pulmonary collapse,Celiac artery compression syndrome,Neoplasm of unspecified nature of respiratory system,Other drugs and medicinal substances causing adverse effects in therapeutic use,Generalized hyperhidrosis,Loss of weight,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Depressive disorder, not elsewhere classified,Unspecified acquired hypothyroidism
Effusion NEC exc tb,Acute kidney failure NEC,Chr diastolic hrt fail,Pulmonary collapse,Celiac art compress syn,Respiratory neoplasm NOS,Adv eff medicinal NEC,Generalizd hyperhidrosis,Abnormal loss of weight,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Anemia in chr kidney dis,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,Hx TIA/stroke w/o resid,Hyperlipidemia NEC/NOS,Athscl extrm ntv art NOS,Migrne unsp wo ntrc mgrn,Gstr/ddnts NOS w/o hmrhg,Depressive disorder NEC,Hypothyroidism NOS
Admission Date:  [**2173-3-25**]              Discharge Date:   [**2173-3-31**]

Date of Birth:  [**2096-3-12**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult /
Shellfish

Attending:[**Male First Name (un) 4578**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
cath

History of Present Illness:
77 y/o F PMH significant CAD s/p several stents, DM,
hyperlipidemia, HTN who presents with shortness of breath of 2
days duration. Patient reports difficulty breathing at rest and
with exertion. She denies any associated chest pain. She reports
baseline ankle edema. She denies orthopenia and PND. She denies
any chest pain or SOB since her cath in [**Month (only) **]. She denies
sick contacts, fevers, [**Name2 (NI) **], increased sputum production, sore
throat and muscle aches. She reports nausea and episode of soft
stool yesterday. She denies bloody or black stool.
.
Patient presented to [**Location (un) 620**] ED - reported to be hypoxic with
improvement on NC. Initial vitals T 100.3, Tm 100.8, P 107, RR
20, Bp 137/62, O2Sat 87% RA. Concern for PNA based on CXR and
given Ceftriaxone/Azithromycin. Per report no EKG changes and
given 4 baby aspirin. Troponin elevated 0.28 consequently
transferred to [**Hospital1 18**] for further management. On arrival to
[**Location (un) 86**] [**Hospital1 18**] T 96.9, BP 124/63, HR 82, RR 18, 97% 4L. Patient
normotensive. O2 sat 97-98% 2-3L. Nitro drip started. Ordered
for 1 pRBC but not hung prior to transfer. Guaiac negative.
.
Patient had recent admission [**Date range (1) **] for NSTEMI s/p DES to
LM, LAD and RCA during the course of two catheterizations.
Metoprolol and Norvasc increased, Hydralazine started. Patient
transfused 2 units for angioseal bleed. CT scan ruled out RP
bleed. Acute on chronic renal failure - felt to be related to
contrast load in cath and required ultrafiltration in CCU.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

2. CARDIAC HISTORY:
-Extensive CAD s/p multiple stents
-CABG: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# H/o CVA [**2157**]
# Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**]
followed by [**Doctor Last Name **])
# PVD
# DM II - not on insulin, most recent A1c 7.1 in [**6-25**]
# Hypertension
# Migraine headaches
# Gastritis - no peptic ulcer disease history.
# Depression x30 years, initially reactive


Social History:
Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner.


Family History:
Mother had CAD and MI. Father died at a young age of MI.

Physical Exam:
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, jvd to clavicle
RESP: Decreased breath sounds left base. Mild wheezes
throughout. No crackles.
CV: RR, S1 and S2 wnl, 3/6 systolic ejection murmur radiates
throughout.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. 5/5 strength throughout.
RECTAL: Guaiac negative.


Pertinent Results:
Labs on admission:
[**2173-3-25**] 12:55AM BLOOD WBC-9.9 RBC-2.64* Hgb-7.9*# Hct-23.0*#
MCV-87 MCH-29.9 MCHC-34.3 RDW-14.2 Plt Ct-390
[**2173-3-25**] 12:55AM BLOOD Neuts-82.3* Lymphs-13.2* Monos-4.0
Eos-0.2 Baso-0.3
[**2173-3-25**] 12:55AM BLOOD PT-14.0* PTT-31.3 INR(PT)-1.2*
[**2173-3-25**] 12:55AM BLOOD Glucose-201* UreaN-40* Creat-1.4* Na-142
K-4.2 Cl-109* HCO3-20* AnGap-17
[**2173-3-25**] 06:29AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.2 Iron-15*
.
CE trend:
[**2173-3-25**] 12:55AM BLOOD proBNP-[**Numeric Identifier 99917**]*
[**2173-3-25**] 12:55AM BLOOD cTropnT-0.30*
[**2173-3-25**] 06:29AM BLOOD CK-MB-4 cTropnT-0.33*
[**2173-3-25**] 04:00PM BLOOD CK-MB-5 cTropnT-0.46*
[**2173-3-26**] 05:26AM BLOOD CK-MB-4 cTropnT-0.56*
.
Labs on discharge from MICU:
[**2173-3-26**] 05:26AM BLOOD WBC-8.2 RBC-3.84*# Hgb-11.5*# Hct-32.9*
MCV-86 MCH-29.8 MCHC-34.8 RDW-14.6 Plt Ct-408
[**2173-3-26**] 05:26AM BLOOD Glucose-133* UreaN-38* Creat-1.4* Na-141
K-4.4 Cl-107 HCO3-24 AnGap-14
[**2173-3-26**] 05:26AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.1
[**2173-3-25**] 06:29AM BLOOD Calcium-8.5 Phos-5.6*# Mg-2.2
.
DISCHARGE LABS
[**2173-3-31**] 09:05AM BLOOD WBC-8.1 RBC-3.82* Hgb-11.3* Hct-34.0*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.1 Plt Ct-574*
[**2173-3-31**] 09:05AM BLOOD Glucose-178* UreaN-41* Creat-2.3* Na-141
K-4.2 Cl-105 HCO3-23 AnGap-17
[**2173-3-31**] 09:05AM BLOOD Calcium-9.0 Phos-5.1* Mg-2.4
.
Iron studies:
Iron-15*
[**2173-3-25**] 06:29AM BLOOD calTIBC-157* Ferritn-654* TRF-121*
.
CXR on admission:
1) Persistent loculated left effusion with increasing fluid
within the left pleural cavity and new partial left lower lobe
atelectasis.
2) New mild pulmonary edema.
3) New small right pleural effusion.
.
ECHO [**2173-3-25**]: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Elevated left ventricular filling pressures.
Mild aortic stenosis with mild aortic regurgitation. Mild to
moderate mitral and tricuspid regurgitation. Mild pulmonary
artery systolic hypertension. Very small to small anterior
pericardial effusion.
.
CARDIAC CATH [**2173-3-26**] (PRELIMINARY REPORT): Coronary
Angiography- Right domimant LMCA- Stent widely patent. Because
of the proximal mild lucency, it was interrogated with pressure
wire that showed FFR of 0.92 indicative of no significant
disease.
LAD- Patent mid LAD stent with 30% ISR, no other significant
disease
LCX- Small vessel with no significant disease
RCA- All stents are widely patent. Mild mid PDA disease.
FINAL DIAGNOSIS:
1. Widely patent stents in LMCA, LAD and RCA
2. Mildly elevated LVEDP
3. Minimal aortic valve gradient
.
CT CHEST WITHOUT CONTRAST [**2173-3-27**]:
The trachea and central airways are patent to the subsegmental
level. There is mild senile calcification of the
tracheobronchial tree. The aorta and great vessels are normal in
caliber and contour, though dense calcification of the aorta, as
well as dense calcification of the right and left coronary
arteries, is noted. The heart is normal in size. There is a
small pericardial effusion. There is no mediastinal or hilar
adenopathy identified. The esophagus appears normal.
Calcification of the aortic valve is also noted. There are small
bilateral pleural effusions, though the effusion on the right
has slightly increased compared to [**2172-11-18**]. This is simple
fluid in attenuation. On the left, the amount of pleural fluid
is likely unchanged, also simple fluid in attenuation. There is
a focal higher-density region at the periphery of the lingula
and left lower lobe, which might represent rounded atelectasis,
which appears slightly larger than on the prior study.
Within the lungs, there is a small calcified granuloma seen at
the left base (2:25). There are no additional pulmonary nodules
or masses identified. Apical pleural scarring is seen
bilaterally. In the visualized upper abdomen, visualized liver,
spleen, and adrenal glands are normal. Hyperdense material in
the upper pole of the left renal collecting system likely
represents retained contrast from cardiac catheterization
performed one day prior.
BONE WINDOWS: Degenerative changes are noted in the thoracic
spine. No
suspicious lytic or sclerotic osseous lesions identified.
IMPRESSION:
1. Bilateral small simple pleural effusions, likely unchanged on
the left and slightly increased on the right.
2. Probable subpleural rounded atelectasis/collapse in the
lingula and left lower lobe, slightly worse in appearance since
the most recent comparison of [**2172-11-18**]. The oval
hyperdense mass previously seen in the pleural space anteriorly
adjacent to the lingula on [**2172-11-18**] might also represent
a focus of atelectasis/collapse. Recommend followup imaging
after resolution of pleural effusions to assess stability of
findings.
3. Dense aortic and coronary atherosclerotic calcification, with
additional calcification of the aortic valve.
4. Retained contrast within the renal collecting system
secondary to recent cardiac catheterization.

Brief Hospital Course:
77 y/o F PMH significant CAD s/p stents, DM, hyperlipidemia, HTN
who presented with shortness of breath of 2 days duration, found
to have large pleural effusions and was diuresed.  Hospital
course complicated by episode concerning for ACS but taken to
cardiac cath and stents found to be patent.  On discharge
breathing well, but continued to have drenching night sweats
which will require very close outpatient follow-up.
.
# Pleural effusions/Acute Diastolic Heart Failure: Most likely
secondary to CHF and pleural effusion. Patient reports recent
increase in salt intake (Chinese, Pizza over the weekend).
Improved with diuresis on lasix drip (greater than 2 L) during
stay. Pleural effusion (chronic) most likely secondary to CHF
but other possibility is malignancy based on CT scan last
admission with ? lung lesion. CXR demonstrates loculated left
pleural effusion and left lower lobe collapse. Transthoracic
echocardiogra showed preserved EF, 1+ MR, and elevated left
ventricular end-diatolic pressures.  Following diuresis, pt went
to cath which found LVEDP 12, demonstrating euvolemia
consequently lasix drip stopped prior to transfer to cardiology.
 On cardiology service, patient was successfully weaned off
oxygen and breathing comfortably.  Repeat imaging showed
improvement in pleural effusions after diuresis and no
thoracentesis was pursued.  The possibility of malignant
effusions cannot be ruled out.  Repeat CT of the chest reported
that they hyperdense mass commented on CT from [**2172-11-18**] is
most likely rounded atelectasis, and not a mass; however repeat
imaging after resolution of pleural effusions is recommended.
The patient has had thoracentesis on previous admissions sent
for cytology and found to be negative for malignancy.  She may
benefit from repeat diagnostic thoracentesis in future if
pleural effusions reaccumulate.  She was discharged on po lasix
20 mg daily.
.
# Type B symptoms:  Pt reports several months of night sweats
and indeed had drenching night sweats while an inpatient.  She
also notes a [**10-7**] pound weight loss over past 2-3 months.
These symptoms are highly concerning for occult malignancy or
chronic infection.  There was a concerning area on Chest CT from
[**2172-11-18**] which seemd more likely to represent rounded
atelectasis on repeat CT from this admission.  Follow-up imaging
is recommended after resolution of pleural effusions.  Of note,
thoracentesis from [**2172-11-18**] was consistent with
transudative process and cytology was negative for malignancy.
.
# CAD: EKG on admission t-wave flattening and inversions
anterior leads. Patient had episode of acute nausea/diaphoresis
[**2173-3-25**] with EKG changes borderline ST elevation V1/V2,
depression V4-V6. Patient with mild diaphoresis morning [**2173-3-26**]
and continued to have ST depressions V4-V6. Troponins increased
in setting of worsening renal function, but CK-MB remained flat.
Patient started on a heparin drip and underwent cath which
demonstrated no in-stent thrombosis. Heparin drip was stopped.
ASA and [**Month/Day/Year 4532**] continued throughout stay.
.
# Anemia:  Guaiac negative.  Likely secondary to chronic kidney
disease with a question of contribution from other systemic
source of inflammation (? occult malignancy).  Responded to 1
pRBC. Iron studies consistent with anemia of chronic
inflammation.
.
# Acute on Chronic Renal failure: Improved from baseline.
Losartan was held as patient was at high risk of contrast
nephropathy following cath, last cath on CVVH due to renal
failure. Given mucomyst and IVF following cath.  Pt did develop
contrast induced nephropathy after cath with Cr peaking at 3.3.
Renal Consult was called.  Pt was monitored and Cr improved
prior to discharge (down to 2.3) with expected continued
improvement.  Of note, losartan was held on discharge but should
be restarted as an outpatient.
.
# Diabetes: Held metformin and placed on insulin sliding scale
in house.  Discharged on home metformin.
.
# Hyperlipidemia: Continued lipitor.
.
# Hypertension: Continued Hydralazine, Norvasc, Metoprolol
.
# Depression/Psych: Continued trazadone, remeron, ritalin.
.
# Hypothyroidism: Continued home dose Levothyroxine 100 mcg cap.
.
# Transition of Care:
-Pt requires close follow-up for highly concerning symptoms of
persistent night sweats and weight loss.
-Pt needs follow-up chest imaging with resolution of pleural
effusions.
-Pt should have creatinine checked in next 2-4 weeks to ensure
return to previous renal function.
-Pt's losartan should be re-started as an outpatient.
-Pt needs further teaching regarding adherence to low salt diet.

Medications on Admission:
Per Needhem Med Rec - patient does not know
- Losartan 50 mgs qd
- Levothyroxine 100 mcg cap
- Hydralazine 50 mg TID
- Imdur 120 mg 24 hour daily
- Lipitor 80 mg tab
- Metformin ER 500 mg qd
- Prilosec 20 mg [**Hospital1 **]
- [**Hospital1 **] 75 mg qd
- Trazadone 75 mgs qhs
- Remeron 30 mg qhs
- Norvasc 10 mg qd
- Metoprolol tartate 150 mgs [**Hospital1 **]
- ASA 81 mg
- Ambien 5 mg
- Lasix 20 mg
- Ritalin 5 mg 1 qam and 1 qpm
- Nitro prn


Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Imdur 120 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. trazodone 50 mg Tablet Sig: 1.5 Tablets PO at bedtime.
9. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
15. Ritalin 5 mg Tablet Sig: One (1) Tablet PO twice a day.
16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual three times a day as needed for chest pain: can take
1 tablet every 5 minutes for up to three tablets for chest pain.



Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis: Bilateral pleural effusions, Acute Renal
Failure, Contrast Induced Nephropathy
.
Secondary Diagnoses: Coronary artery disease


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


Discharge Instructions:
You were admitted to the hospital for shortness of breath.  You
were found to have fluid around your lungs.  You were given
diuretics to help remove extra fluid from your lungs.  You had
an episode that was concerning for a cardiac event.  You were
taken to the cath lab where we found the blood vessels supplying
your heart, including those with stents, to all be patent.  You
developed an injury to your kidneys from the contrast dye used
during the catherization.  Your kidneys recovered on their own
and you were discharged home.  You have a follow-up with Dr.
[**Last Name (STitle) 2903**] (see below) during which you should be evaluated for your
night sweats.
.
The following change was made to your medications:
-- STOP losartan.  Dr. [**Last Name (STitle) 2903**] should restart this medication after
your kidneys have completely recovered.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.  Please be sure to limit the amount of salt in your
diet to less than 2 grams daily.
.
It was a pleasure taking care of you.

Followup Instructions:
Department: [**State **]When: TUESDAY [**2173-4-6**] at 12:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: On Street Parking
{'Other specified forms of effusion, except tuberculous,Acute kidney failure with other specified pathological lesion in kidney,Chronic diastolic heart failure,Pulmonary collapse,Celiac artery compression syndrome,Neoplasm of unspecified nature of respiratory system,Other drugs and medicinal substances causing adverse effects in therapeutic use,Generalized hyperhidrosis,Loss of weight,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Depressive disorder, not elsewhere classified,Unspecified acquired hypothyroidism'}


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: 77 y/o F PMH significant CAD s/p several stents, DM,
hyperlipidemia, HTN who presents with shortness of breath of 2
days duration. Patient reports difficulty breathing at rest and
with exertion. She denies any associated chest pain. She reports
baseline ankle edema. She denies orthopenia and PND. She denies
any chest pain or SOB since her cath in [**Month (only) **]. She denies
sick contacts, fevers, [**Name2 (NI) **], increased sputum production, sore
throat and muscle aches. She reports nausea and episode of soft
stool yesterday. She denies bloody or black stool.
.
Patient presented to [**Location (un) 620**] ED - reported to be hypoxic with
improvement on NC. Initial vitals T 100.3, Tm 100.8, P 107, RR
20, Bp 137/62, O2Sat 87% RA. Concern for PNA based on CXR and
given Ceftriaxone/Azithromycin. Per report no EKG changes and
given 4 baby aspirin. Troponin elevated 0.28 consequently
transferred to [**Hospital1 18**] for further management. On arrival to
[**Location (un) 86**] [**Hospital1 18**] T 96.9, BP 124/63, HR 82, RR 18, 97% 4L. Patient
normotensive. O2 sat 97-98% 2-3L. Nitro drip started. Ordered
for 1 pRBC but not hung prior to transfer. Guaiac negative.
.
Patient had recent admission [**Date range (1) **] for NSTEMI s/p DES to
LM, LAD and RCA during the course of two catheterizations.
Metoprolol and Norvasc increased, Hydralazine started. Patient
transfused 2 units for angioseal bleed. CT scan ruled out RP
bleed. Acute on chronic renal failure - felt to be related to
contrast load in cath and required ultrafiltration in CCU.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension

MEDICATION ON ADMISSION: Per Needhem Med Rec - patient does not know
- Losartan 50 mgs qd
- Levothyroxine 100 mcg cap
- Hydralazine 50 mg TID
- Imdur 120 mg 24 hour daily
- Lipitor 80 mg tab
- Metformin ER 500 mg qd
- Prilosec 20 mg [**Hospital1 **]
- [**Hospital1 **] 75 mg qd
- Trazadone 75 mgs qhs
- Remeron 30 mg qhs
- Norvasc 10 mg qd
- Metoprolol tartate 150 mgs [**Hospital1 **]
- ASA 81 mg
- Ambien 5 mg
- Lasix 20 mg
- Ritalin 5 mg 1 qam and 1 qpm
- Nitro prn

ALLERGIES: Penicillins / Univasc / Tetanus & Diphtheria Tox,Adult /
Shellfish

PHYSICAL EXAM: GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, jvd to clavicle
RESP: Decreased breath sounds left base. Mild wheezes
throughout. No crackles.
CV: RR, S1 and S2 wnl, 3/6 systolic ejection murmur radiates
throughout.
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. 5/5 strength throughout.
RECTAL: Guaiac negative.

FAMILY HISTORY: Mother had CAD and MI. Father died at a young age of MI.

SOCIAL HISTORY: Widowed, daughter lives with her. Previously independent.
-Tobacco history: Denies
-ETOH: Will have one drink when she goes out to dinner. 

### Response:
{'Other specified forms of effusion, except tuberculous,Acute kidney failure with other specified pathological lesion in kidney,Chronic diastolic heart failure,Pulmonary collapse,Celiac artery compression syndrome,Neoplasm of unspecified nature of respiratory system,Other drugs and medicinal substances causing adverse effects in therapeutic use,Generalized hyperhidrosis,Loss of weight,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities, unspecified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Depressive disorder, not elsewhere classified,Unspecified acquired hypothyroidism'}
