CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: This is a 75 yof with hx of CAD s/p cardiac cath with RCA stent
in [**2-/2136**], HTN, Hyperlipidemia, GERD, Afib, diastolic
dysfunction, pericardial effusion, pulmonary HTN who presented
to [**Hospital3 **] after 7 days of increasing SOB, 3lb weight
gain.

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Atrial fibrillation
S/P TIA
Depression
Bilateral cataract surgery
Angina
Pneumonia/ Bronchitis
GERD
Anemia
Arthritis
Irritable bowel syndrome
Chronically elevated WBC for past 8 years
s/p TAH/BSO - also reports history of R "ovary explosion" as a
young adult
Hx cholecystectomy and appendectomy

MEDICATION ON ADMISSION: Calcium/Vit D [**Hospital1 **]
Folic Acid 1
Toprol 100 [**Hospital1 **]
Norvasc 5
Mag Oxide 400 [**Hospital1 **]
Iron 325 [**Hospital1 **]
Imdur 120 qam
Lisinopril 40 daily
ASA 81
Omeprazole 20 [**Hospital1 **]
Oxcarbazepine 150 [**Hospital1 **]
Prozac 40
Bumex 3
Colchicine 0.6
Calcitonin INH
Coumadin 5 qhs
Lipitor 80
Flonase nasal
Lidoderm prn
Vicodin prn
tylenol prn
Nitro prn
xanax prn

ALLERGIES: Sulfa (Sulfonamides) / Codeine / Diazepam / Benzodiazepines /
Iodine

PHYSICAL EXAM: VS: T=97.8, BP=141/64, HR=90, RR=22, O2 sat=93-96% on 3l
GENERAL: Obses Caucasian Elderly Female in tripod position
tachypneic on 3 l NC saturating well.
HEENT: EOMI, MMM
NECK: JVP significantly elevated
CARDIAC: S1, S2, ?pericardial rub, tachycardic to 110
irregularly, irregular. Pulsus Paradoxus 8.
LUNGS: Crackles noted b/l mid thorax down.
ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness.
EXTREMITIES: 2+ mixed edema to the knees b/l.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.  Pt is a widow, lives in [**Location 5110**]. Has 6
children and 17 grandchildren

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Hx of tobacco last use [**2103**] - 2-3 packs/day X 15yrs. There
is no history of alcohol abuse.
Unspecified disease of pericardium,Acute on chronic diastolic heart failure,Primary pulmonary hypertension,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status
Pericardial disease NOS,Ac on chr diast hrt fail,Prim pulm hypertension,Acute kidney failure NOS,Lymph/hematpoitc tis NEC,Mental disor NEC oth dis,Other alter consciousnes,Anemia NOS,Chr airway obstruct NEC,Obstructive sleep apnea,Atrial fibrillation,Hypertension NOS,Hyperlipidemia NEC/NOS,Esophageal reflux,Crnry athrscl natve vssl,Status-post ptca
Admission Date:  [**2137-4-29**]              Discharge Date:   [**2137-5-5**]

Date of Birth:  [**2061-10-28**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Codeine / Diazepam / Benzodiazepines /
Iodine

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
Pericardiocentesis, Right heart catheterization


History of Present Illness:
This is a 75 yof with hx of CAD s/p cardiac cath with RCA stent
in [**2-/2136**], HTN, Hyperlipidemia, GERD, Afib, diastolic
dysfunction, pericardial effusion, pulmonary HTN who presented
to [**Hospital3 **] after 7 days of increasing SOB, 3lb weight
gain.

Upon review of [**Hospital1 **] records it appears pt was treated for CHF
exacerbation, an Echo was performed which showed significant
pulmonary HTN in the 90s, preserved EF and moderate sized
effusion in the posterior aspect, small anterior pericardial
effusion. During her admission she was also noted to be anemic
with a Hct of 25 from a previously established Hct of 32 and was
transfused 2u PRBCs. Following her Echo findings of an effusion
as well as pulmonary HTN pt was transferred to [**Hospital1 18**] for right
cardiac catheterization and evaluation for possible pericardial
effusion.

Pt denies any current chest palpitations, pain, pre-syncope
symptoms. She does endorse some shortness of breath which is
worse than when she was at home but the same as it was in [**Hospital1 2519**]. She endorses a cough with productive white/grey
sputum. She endorses diarrhea which she has had for months,
usually watery. She denies any n/v/f/c, abdominal pain, focal
numbness and tingling.


Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
S/P TIA
Depression
Bilateral cataract surgery
Angina
Pneumonia/ Bronchitis
GERD
Anemia
Arthritis
Irritable bowel syndrome
Chronically elevated WBC for past 8 years
s/p TAH/BSO - also reports history of R "ovary explosion" as a
young adult
Hx cholecystectomy and appendectomy

Cardiac Risk Factors: Hyperlipidemia, Hypertension

Percutaneous coronary intervention - reports previous cath,
unsure of date and location


Social History:
Social history is significant for the absence of current tobacco
use. Hx of tobacco last use [**2103**] - 2-3 packs/day X 15yrs. There
is no history of alcohol abuse.


Family History:
There is no family history of premature coronary artery disease
or sudden death.  Pt is a widow, lives in [**Location 5110**]. Has 6
children and 17 grandchildren

Physical Exam:
VS: T=97.8, BP=141/64, HR=90, RR=22, O2 sat=93-96% on 3l
GENERAL: Obses Caucasian Elderly Female in tripod position
tachypneic on 3 l NC saturating well.
HEENT: EOMI, MMM
NECK: JVP significantly elevated
CARDIAC: S1, S2, ?pericardial rub, tachycardic to 110
irregularly, irregular. Pulsus Paradoxus 8.
LUNGS: Crackles noted b/l mid thorax down.
ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness.
EXTREMITIES: 2+ mixed edema to the knees b/l.


Pertinent Results:
IMAGING of RELEVANCE:

[**2137-4-29**] ECHO The left atrium is markedly dilated. The right
atrium is markedly dilated. Left ventricular cavity size is
normal. Left ventricular wall thicknesses are normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. There is a large pericardial
effusion. The effusion appears circumferential, but is largest
(> 3cm) posterior to the left ventricle. There is approximately
1 cm of fluid anterior to the right ventricle. There are no
echocardiographic signs of tamponade.

Compared with the prior study (images reviewed) of [**2136-3-2**],
the pericardial effusion is larger. The severity of tricuspid
regurgitation is increased. Estimated pulmonary artery pressures
are higher. The right ventricular cavity size appears enlarged
with global hypokinesis. The ventricular rate is faster.
.
[**5-1**]/ECHO
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
There is a moderate sized, echo dense inferior and
inferolateraly pericardial effusion without evidence for
hemodynamic compromise.

Compared with the prior study (images reviewed) of [**2137-4-30**],
the pericardial effusion is now larger and echo dense suggestive
of thrombus/clot. In retrospect, a smaller echo dense
pericardial effusion may have been present on the prior study,
but if so, the effusion is larger and much more apparent on the
current study.
Clinical correlation and serial evaluation is suggested.

------------------

LABS of RELEVANCE:
.

[**2137-5-5**] 04:55AM BLOOD WBC-21.8* RBC-3.19* Hgb-9.2* Hct-28.2*
MCV-88 MCH-28.8 MCHC-32.6 RDW-18.3* Plt Ct-389
[**2137-5-4**] 05:08AM BLOOD WBC-22.5* RBC-3.24* Hgb-9.1* Hct-28.2*
MCV-87 MCH-28.2 MCHC-32.3 RDW-18.2* Plt Ct-421
[**2137-5-3**] 05:40AM BLOOD WBC-22.5* RBC-3.09* Hgb-8.7* Hct-26.9*
MCV-87 MCH-28.2 MCHC-32.5 RDW-18.9* Plt Ct-397
[**2137-5-2**] 05:15AM BLOOD WBC-28.4* RBC-3.36* Hgb-9.4* Hct-29.5*
MCV-88 MCH-28.1 MCHC-32.0 RDW-18.3* Plt Ct-457*
[**2137-5-1**] 05:00AM BLOOD WBC-23.1* RBC-3.18* Hgb-9.1* Hct-27.3*
MCV-86 MCH-28.6 MCHC-33.3 RDW-18.8* Plt Ct-462*
[**2137-4-30**] 06:40AM BLOOD WBC-24.7* RBC-3.15* Hgb-9.0* Hct-26.9*
MCV-85 MCH-28.5 MCHC-33.4 RDW-18.7* Plt Ct-472*
[**2137-4-29**] 07:17PM BLOOD WBC-21.8* RBC-3.20*# Hgb-9.0*# Hct-27.3*#
MCV-85 MCH-28.1 MCHC-33.0 RDW-18.6* Plt Ct-503*
[**2137-5-2**] 05:15AM BLOOD Neuts-94* Bands-3 Lymphs-2* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2137-5-1**] 05:00AM BLOOD Neuts-94* Bands-0 Lymphs-3* Monos-1*
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2137-5-5**] 04:55AM BLOOD PT-19.4* PTT-33.4 INR(PT)-1.8*
[**2137-5-4**] 01:30PM BLOOD PT-19.9* PTT-32.8 INR(PT)-1.9*
[**2137-5-2**] 05:15AM BLOOD PT-17.3* PTT-32.0 INR(PT)-1.6*
[**2137-5-1**] 05:00AM BLOOD PT-16.1* PTT-31.9 INR(PT)-1.4*
[**2137-5-5**] 04:55AM BLOOD Glucose-132* UreaN-53* Creat-1.1 Na-142
K-4.9 Cl-98 HCO3-33* AnGap-16
[**2137-5-4**] 05:08AM BLOOD Glucose-107* UreaN-55* Creat-1.2* Na-142
K-4.7 Cl-101 HCO3-32 AnGap-14
[**2137-5-3**] 05:40AM BLOOD Glucose-104 UreaN-57* Creat-1.1 Na-141
K-3.6 Cl-97 HCO3-31 AnGap-17
[**2137-5-2**] 05:15AM BLOOD Glucose-132* UreaN-60* Creat-1.3* Na-140
K-4.1 Cl-97 HCO3-30 AnGap-17
[**2137-5-1**] 03:44PM BLOOD UreaN-62* Creat-1.4* Na-138 K-4.1 Cl-96
HCO3-30 AnGap-16
[**2137-5-1**] 05:00AM BLOOD Glucose-247* UreaN-62* Creat-1.3* Na-131*
K-4.1 Cl-92* HCO3-27 AnGap-16
[**2137-4-30**] 06:40AM BLOOD Glucose-123* UreaN-67* Creat-1.4* Na-132*
K-5.1 Cl-94* HCO3-25 AnGap-18
[**2137-4-30**] 06:40AM BLOOD LD(LDH)-703* CK(CPK)-28
[**2137-4-29**] 07:17PM BLOOD CK(CPK)-27
[**2137-4-30**] 06:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2137-4-29**] 07:17PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2137-5-5**] 04:55AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8
[**2137-5-4**] 05:08AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.9
[**2137-5-1**] 03:44PM BLOOD calTIBC-194* Ferritn-717* TRF-149*
[**2137-5-2**] 02:38PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2137-4-29**] 08:26PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2137-5-2**] 02:38PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2137-4-29**] 08:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2137-5-2**] 02:38PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-NONE
Epi-0-2

PERICARDIAL EFFUSION:
[**2137-4-30**] 04:30PM OTHER BODY FLUID WBC-1000* Hct,Fl-<2.0
Polys-84* Lymphs-5* Monos-10* Eos-1*
[**2137-4-30**] 04:30PM OTHER BODY FLUID TotProt-6.0 Glucose-100
LD(LDH)-642 Amylase-21 Albumin-2.8


Brief Hospital Course:
# CORONARIES: Pt noted to have mild Troponin leak of 0.02-0.04
in the setting of poor renal perfusion. Pt has CAD with h.o.
stent to the RCA. Do not suspect current ichemia given lack of
ST changes during hospitalization. Pt was continued on home
regimen of Metoprolol, Atorvastatin, ASA

# PUMP: During admission pt was noted to be hypervolemic on
examination with diffuse crackles on pulmonary auscultation,
mixed 2+ edema in b/l lower extremities. Pt was started on a
Furosemide gtt for diuresis and then transitioned to a PO
regimen of Furosemide 80mg [**Hospital1 **]. Pt was instructed to weigh
herself every morning and call her Cardiologist if she noted any
difference of more than 2 lbs.

# RHYTHM: During hospitalization pt was noted to be in A.
fibrillation initially with rapid ventricular response of
120-130. On day of transfer pt was noted to have SOB with a rate
in the 140s after which she received IV Metoprolol 5mg Tartrate
with response of heart rate within 100-120. Pt was changed to
Metoprolol 100mg Taretrate TID, a heart rate of 100-120 was
tolerated given the presence of hypoxia, pulmonary HTN,
pericardial effusion. Pt was restarted on her Coumadin prior to
discharge.

# Pericardial Effusion: Pt was noted to have 2 pericardial
effusions, moderate size in the posterior aspect, small effusion
in the anterior portion. Pt underwent pericardiocentesis that
was noted to show 800cc serosanguinous fluid. Analysis of fluid
showed WBC 1000 but negative on fluid culture, anaerobic
culture, AFB smear. Gram stain also nowed no microorganisms and
2+ Polymorphonuclear leukocytes. Cytology was also negative, an
autoimmune panel of [**Doctor First Name **], double stranded DNA were still pending
at time of discharge but unlikely to be positive given her lack
of symptoms in the past. Following pericardiocentesis pt was
noted to have an echodensity collection thought to be clot
formation. Re-examination with repeat Echos showed no changes
thus indicating no unstable bleed into the pericardium. Suspect
that the collection has always been present but hidden from
prior Echos because of the pericardial fluid superimposed around
it.
- Recommend pt undergo repeat Echo in 1 week to again reassess
pericardium, specifically possibility of constrictive
pericarditis.

# Psych: During hospitalization pt was noted to be
intermittently confused primarily with delusions of being tied
up or mistreated. Psychiatry were consulted and determined pt
may have been having delirium super imposed on mild dementia.
Per Psych recommendations pt was started on Seroquel at bedtime.
Alprazolam was discontinued due it's increased risk of Delirium.
Prior to discharge pt agreed to Psychiatry follow up as an
outpatient, Psychiatry touched base with pt's PCP regarding this
issue.

# Pulmonary HTN: Pt has a history of Pulmonary HTN per transfer
summary, it appears she was started on oxygen last [**Month (only) 359**] for
it but has never been worked up. She last saw a Pulmonologist
several years ago for her asthma. Her reason for transfer was
due to her noted pulmonary pressures in the 90s-100s on Echo,
right heart cath was performed to determine whether etiology is
cardiac versus Pulmonary. Her right heart cath pressures are
notable for a high mean pressure, higher PA diastolic pressure
when compared to the wedge (which is elevated by itself). From
her right heart cath results it is likely that there is a
cardiac component superimposed on a pulmonary one given the
elevated Wedge with an even greater PA diastolic pressure. I
clinically suspect that there are two processes going on - acute
and chronic. Her diastolic dysfunction and fluid overload state
are likely the acute causes of her pulmonary HTN. I do believe
though that she does have a chronic underlying pulmonary HTN
that is due to a pulmonary process. Pt has OSA and is
intermittently non-adherent to it which is likely a component,
pt also has a smoking history and may have a COPD component too
(no PFTs available). Pt also has a history notable for numerous
pneumonias as a child and adult, it is possible that with
recurrent infection that may be some pulmonary fibrosis which
may be working in addition to the aforementioned OSA and COPD.
Autoimmune conditions such as Rh. Arthritis, Lupus may also
cause pulmonary HTN particularly given her pericardial effusion,
pleural effusion. She does not though have any prior history of
autoimmune symptoms and it would be atypical for her first
presentation to be at this age. Chronic PEs is another diagnosis
to consider however prior to this transfer she had been on
Coumadin for her A. fib. Unfortunately further studies such as
PFTs, high-res Chest CT are not helpful given her current
hypervolemic status. Discussed this with family who preferred a
pulmonary physician in [**Hospital3 **].
- Recommend pt set up Pulmonary appointment for Pulmonary HTN
work up
- pt discharged onb home regimen of 2l NS to be worn at all
times
- encouraged pt to continue her CPAP at home

# Leukocytosis: Pt has history of leukocytosis from her
myelodysplastic syndrome. On review of her records from [**Hospital1 2519**] it appears her WBC trended up and then down from
16.1->25.3 over several days and then trended down to 23.3 prior
to transfer. Her WBC has been trending up during this
hospitalization from 21.8->24.7->23.1->28.4->22.5->22.5->21.8.
Likely due to her MDS as she did not show any signs of infection
during admission.

# OSA: Continued pt in hospital on CPAP. Recommended she
continue it as an outpatient.

# Myeloproliferative d/o: Pt has JAK-2 mutation with a history
of leukocytosis. Pt was previously on hydroxyurea when she was
noted to be in polycythemia [**Doctor First Name **]. Following a decrease in her
Hct she was then transitioned briefly to Procrit.
No [**First Name9 (NamePattern2) **] [**Doctor First Name **] or anemia noted during hospitalization.

# HTN: Pt was continued on Amlodipine and Metoprolol.

# GERD: Pt was continued on Omeprazole and Maalox PRN.

# Depression: Pt was conrinued on her home regimen of Fluoxetine
daily.


Medications on Admission:
Calcium/Vit D [**Hospital1 **]
Folic Acid 1
Toprol 100 [**Hospital1 **]
Norvasc 5
Mag Oxide 400 [**Hospital1 **]
Iron 325 [**Hospital1 **]
Imdur 120 qam
Lisinopril 40 daily
ASA 81
Omeprazole 20 [**Hospital1 **]
Oxcarbazepine 150 [**Hospital1 **]
Prozac 40
Bumex 3
Colchicine 0.6
Calcitonin INH
Coumadin 5 qhs
Lipitor 80
Flonase nasal
Lidoderm prn
Vicodin prn
tylenol prn
Nitro prn
xanax prn



Discharge Medications:
1. Oxygen Prescription
Pt will need Oxygen at all times on 2lpm
2. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal QHS (once a day (at bedtime)).
Disp:*1 bottle* Refills:*2*
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Please take at 8am.
Disp:*30 Tablet(s)* Refills:*2*
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation four times a day.
Disp:*1 inhaler* Refills:*2*
14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day:
Please take at 1600.
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Lab Work
Please have your blood drawn on [**2137-5-7**]. Please have your blood
collected to check your PTT, PT, INR. Please have the results
faxed ATTN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] Fax number:  ([**Telephone/Fax (1) 41630**].
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Primary: Pericardial Effusion, Pulmonary Hypertension, Delirium,
CHF exacerbation, A. Fib, delirium
Secondary: Mild dementia, Hypertensionm Hyperlipidemia,
Myelodysplastic syndrome


Discharge Condition:
Stable, afebrile on 2l oxygen


Discharge Instructions:
You were transferred to this hospital for evaluation of your
difficulty breathing, heart failure as well as a fluid
collection around your heart. Whilst in the hospital you
underwent a pericardiocentesis to drain the fluid around your
heart, we also started you on a medication to get rid of the
excess fluid from your heart failure. Prior to your discharge
you were back down to your baseline oxygen requirement of 2
litres, you also were able to walk with physical therapy who
recommended you go home with physical therapy.

We made several changes to your medications.

We started you on 8 new medications:
1. Please take Furosemide 80mg in the morning at 8am
2. Please take Furosemide 80mg in the afternoon at 4pm
3. Please take Questiapine 12.5mg at bedtime
4. Please take Aspirin 325mg once a day
5. Please take Fluticasone 1 nasal spray in each nostril at
bedtime
6. Please take 325mg Ferrous Sulfate once a day
7. Please take Ipratropium Inhaler 2 puffs four times a day
8. Please take Coumadin 2mg at bedtime.

We changed 2 of your medications:
1. Please take Prilosec 40mg once a day instead of 20mg twice a
day.
2. Please take Metoprolol Tartrate 100mg three times a day
instead of twice a day.

We stopped 5 of your old medications:
1. Please stop taking Bumex 3mg daily
2. Please stop taking Norvasc 5mg daily
3. Please stop taking Digoxin 0.25mg daily
4. Please stop taking Imdur 180mg daily
5. Please stop taking Lisinopril 40mg daily

We made no changes to the following medications:
1. Nitroglycerin spray
2. Fluoxetine 40mg daily
3. Atorvastatin 80mg at bedtime
4. Trileptal 150mg twice a day
5. Folic Acid 1mg daily
6. Colchicine 0.6mg daily

Please weigh yourself every day at the same time of day in the
same outfit. If you gain >2lbs please call your Cardiologist.

If you experience any further chest pain, difficulty breathing
please return to the ED.

Followup Instructions:
You have an appointment with your Cardiologist Dr. [**Last Name (STitle) 10543**] on
[**2137-5-7**] at 2:45pm.

You will need a Transthoracic echo in a weeks time to evaluate
the collection in the lining of the heart, this should be set up
through Dr.[**Name (NI) 41631**] office.

You will also need your blood checked as you were restarted on
Coumadin. Please have your blood drawn on [**2137-5-7**] and have the
results faxed over to Dr.[**Name (NI) 41631**] office. His fax number is
([**Telephone/Fax (1) 41630**].

Please make an appointment to see a Pulmonary doctor [**First Name (Titles) **] [**Last Name (Titles) 2519**] in the next two weeks for your pulmonary hypertension.

Please make an appointment to see Dr. [**First Name (STitle) **] within the next
week.

Please make an appointment to see a psychiatrist within the next
two weeks. Please call [**Telephone/Fax (1) 1387**] for an appointment.

Please make an appointment to see your neurologist Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 40860**] to see if you still need to be on Oxcarbazepine.
{'Unspecified disease of pericardium,Acute on chronic diastolic heart failure,Primary pulmonary hypertension,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}


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: This is a 75 yof with hx of CAD s/p cardiac cath with RCA stent
in [**2-/2136**], HTN, Hyperlipidemia, GERD, Afib, diastolic
dysfunction, pericardial effusion, pulmonary HTN who presented
to [**Hospital3 **] after 7 days of increasing SOB, 3lb weight
gain.

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Atrial fibrillation
S/P TIA
Depression
Bilateral cataract surgery
Angina
Pneumonia/ Bronchitis
GERD
Anemia
Arthritis
Irritable bowel syndrome
Chronically elevated WBC for past 8 years
s/p TAH/BSO - also reports history of R "ovary explosion" as a
young adult
Hx cholecystectomy and appendectomy

MEDICATION ON ADMISSION: Calcium/Vit D [**Hospital1 **]
Folic Acid 1
Toprol 100 [**Hospital1 **]
Norvasc 5
Mag Oxide 400 [**Hospital1 **]
Iron 325 [**Hospital1 **]
Imdur 120 qam
Lisinopril 40 daily
ASA 81
Omeprazole 20 [**Hospital1 **]
Oxcarbazepine 150 [**Hospital1 **]
Prozac 40
Bumex 3
Colchicine 0.6
Calcitonin INH
Coumadin 5 qhs
Lipitor 80
Flonase nasal
Lidoderm prn
Vicodin prn
tylenol prn
Nitro prn
xanax prn

ALLERGIES: Sulfa (Sulfonamides) / Codeine / Diazepam / Benzodiazepines /
Iodine

PHYSICAL EXAM: VS: T=97.8, BP=141/64, HR=90, RR=22, O2 sat=93-96% on 3l
GENERAL: Obses Caucasian Elderly Female in tripod position
tachypneic on 3 l NC saturating well.
HEENT: EOMI, MMM
NECK: JVP significantly elevated
CARDIAC: S1, S2, ?pericardial rub, tachycardic to 110
irregularly, irregular. Pulsus Paradoxus 8.
LUNGS: Crackles noted b/l mid thorax down.
ABDOMEN: Soft, obese, NT, ND. No HSM or tenderness.
EXTREMITIES: 2+ mixed edema to the knees b/l.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.  Pt is a widow, lives in [**Location 5110**]. Has 6
children and 17 grandchildren

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Hx of tobacco last use [**2103**] - 2-3 packs/day X 15yrs. There
is no history of alcohol abuse. 

### Response:
{'Unspecified disease of pericardium,Acute on chronic diastolic heart failure,Primary pulmonary hypertension,Acute kidney failure, unspecified,Other lymphatic and hematopoietic tissues,Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Anemia, unspecified,Chronic airway obstruction, not elsewhere classified,Obstructive sleep apnea (adult)(pediatric),Atrial fibrillation,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}
