CHIEF COMPLAINT: Shortness of breath, tachycardia

PRESENT ILLNESS: 74 yo F with PMH significant for pancreatic CA s/p Whipple's
procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C.
diff and UTI, and recent left femur fracture, presents with
shortness of breath and tachycardia, found to have pulmonary
embolism and atrial flutter with RVR.
.
Patient reports that she was experiencing shortness of breath
this AM at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] and was noted to be tachypneic up to
the 30s. Denied chest pain, chest pressure, diaphoresis,
vomiting, syncope. Otherwise, reports diarrhea from C. diff,
increased upper extremity edema over the past 2 days, and
worsening wheeze.
.
Of note, patient was found to have a non-occlusive left
popliteal DVT on LENI in [**2157-5-29**]. Lovenox and IVC filter were
recommended and patient declined both. On [**2157-7-16**], she syncopized
and sustained a fall from standing height at rehab, resulting in
left oblique displaced comminuted midshaft femur fracture. This
was repaired at [**Hospital1 18**] on [**2157-7-20**] when she underwent a retrograde
femoral nail for left femur fracture. Post-operatively, patient
was discharged on prophylaxis dose of lovenox 40 mg/0.4 ml sc
qd.
.
Two day prior to admission, patient noted increased swelling in
her upper extemities. Also reports having a repeat LENI done of
the left leg which showed disappearance of the previously noted
DVT.
.
In the ED, initial VS were 98.2 141 126/87 24 98% 4L Nasal
Cannula. EKG showed A-flutter and she was given an adenosine
challenge. Received IV diltiazem (5 mg x 3) and then diltiazem
gtt, which was stopped after the CTA showed PE. CT head was
performed to ruled out metastasis which was negative. She was
guaiac negative and started on heparin gtt. Labs were notable
for BNP 7400, troponin 0.08, Cr 1.4 (baseline 1.7), positive UA,
and patient was given vancomycin + zosyn. Per report, bedside
echo did not show RV collapse. On transfer, VS were HR 141 BP
109/71 RR 16 O2sat 97% 3L (NC).
.
On the floor, patient was tachypneic and in slight distress.
Denied chest pain however does report wheezing and shortness of
breath.

MEDICAL HISTORY: - Pancreatitis in [**2156-3-15**] at [**Hospital1 112**]. MRI/MRCP on [**2156-9-29**]
showed a 2 cm cystic mass of the pancreatic head with
obstruction of the pancreatic and bile ducts. She underwent ERCP

MEDICATION ON ADMISSION: 1. aspirin 81 mg po qd
2. bupropion HCl 450 mg Tablet Extended Release PO QAM
3. docusate sodium 100 mg PO BID
4. insulin Insulin SC Sliding Scale
5. insulin glargine 22 units qhs
6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) PO TID
7. losartan 50 mg PO BID
8. multivitamin PO DAILY
9. simvastatin 40 mg PO DAILY
10. Flagyl 500 mg PO q8hr (planned for [**2157-7-20**] - [**2157-8-2**])
11. senna 8.6 mg PO BID prn constipation
12. bisacodyl 10 mg PO DAILY (Daily) prn constipation
13. oxycodone 10 mg PO Q3H
14. Tylenol Extra Strength 500 mg PO TID
15. Lovenox 40 mg/0.4 mL 1 syringe qd
16. lorazepam 0.5 mg PO Q8H prn for anxiety.
17. calcium carbonate 200 mg calcium (500 mg) Tablet PO QID (4
times a day) prn for heart burn.

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Morphine / Erythromycin Base /
Desipramine / Ace Inhibitors / Codeine / Nifedipine

PHYSICAL EXAM: Adm PE:

FAMILY HISTORY: Sister with breast cancer, diagnosed at age 58.

SOCIAL HISTORY: Patient lives alone in [**Location (un) 86**], and relies on her sister for
needed support.  She is independent, and cares for herself
without any assistance.  There is no recent ETOH use, no tobacco
use (she quit smoking 25 yrs ago), no illicit drug use.
Other pulmonary embolism and infarction,Other severe protein-calorie malnutrition,Atrial flutter,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Ulcer of other part of lower limb,Body Mass Index 40.0-44.9, adult,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Aftercare for healing traumatic fracture of hip
Pulm embol/infarct NEC,Oth severe malnutrition,Atrial flutter,Int inf clstrdium dfcile,Acute kidney failure NOS,Urin tract infection NOS,Malig neo pancreas NOS,Pleural effusion NOS,Ulcer oth part low limb,BMI 40.0-44.9, adult,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,DMII wo cmp nt st uncntr,Dvrtclo colon w/o hmrhg,Enterococcus group d,Aftrcre traumatic fx hip
Admission Date:  [**2157-8-1**]              Discharge Date:   [**2157-8-18**]

Date of Birth:  [**2083-7-26**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Morphine / Erythromycin Base /
Desipramine / Ace Inhibitors / Codeine / Nifedipine

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Shortness of breath, tachycardia

Major Surgical or Invasive Procedure:
DC Cardioversion


History of Present Illness:
74 yo F with PMH significant for pancreatic CA s/p Whipple's
procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C.
diff and UTI, and recent left femur fracture, presents with
shortness of breath and tachycardia, found to have pulmonary
embolism and atrial flutter with RVR.
.
Patient reports that she was experiencing shortness of breath
this AM at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] and was noted to be tachypneic up to
the 30s. Denied chest pain, chest pressure, diaphoresis,
vomiting, syncope. Otherwise, reports diarrhea from C. diff,
increased upper extremity edema over the past 2 days, and
worsening wheeze.
.
Of note, patient was found to have a non-occlusive left
popliteal DVT on LENI in [**2157-5-29**]. Lovenox and IVC filter were
recommended and patient declined both. On [**2157-7-16**], she syncopized
and sustained a fall from standing height at rehab, resulting in
left oblique displaced comminuted midshaft femur fracture. This
was repaired at [**Hospital1 18**] on [**2157-7-20**] when she underwent a retrograde
femoral nail for left femur fracture. Post-operatively, patient
was discharged on prophylaxis dose of lovenox 40 mg/0.4 ml sc
qd.
.
Two day prior to admission, patient noted increased swelling in
her upper extemities. Also reports having a repeat LENI done of
the left leg which showed disappearance of the previously noted
DVT.
.
In the ED, initial VS were 98.2 141 126/87 24 98% 4L Nasal
Cannula. EKG showed A-flutter and she was given an adenosine
challenge. Received IV diltiazem (5 mg x 3) and then diltiazem
gtt, which was stopped after the CTA showed PE. CT head was
performed to ruled out metastasis which was negative. She was
guaiac negative and started on heparin gtt. Labs were notable
for BNP 7400, troponin 0.08, Cr 1.4 (baseline 1.7), positive UA,
and patient was given vancomycin + zosyn. Per report, bedside
echo did not show RV collapse. On transfer, VS were HR 141 BP
109/71 RR 16 O2sat 97% 3L (NC).
.
On the floor, patient was tachypneic and in slight distress.
Denied chest pain however does report wheezing and shortness of
breath.

Past Medical History:
 - Pancreatitis in [**2156-3-15**] at [**Hospital1 112**]. MRI/MRCP on [**2156-9-29**]
showed a 2 cm cystic mass of the pancreatic head with
obstruction of the pancreatic and bile ducts. She underwent ERCP

on [**2156-10-4**] and a stent was placed. CEA was 32.8 on [**2156-10-5**].
Brushing at the time of ERCP was suspicious for adenocarcinoma.
She had an EUS on [**2156-11-8**] and FNA biopsy revealed malignant
cells consistent with adenocarcinoma. Staging CT on [**2156-11-13**]
revealed a 1.9 cm x 1.6 cm hypoattenuating pancreatic head mass
with post-obstructive pancreatic ductal dilatation to 6mm. No
evidence of local, hepatic or vascular invasion; scattered
celiac axis and porta hepatis LNs measuring up to 1.2 cm. She
was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] surgery service and had
Whipple surgery on [**2156-12-2**]. She had stayed in Rehab until the

beginning of [**2157-1-12**] and then shortly after she was discharged
from rehab, she was admitted to [**Hospital1 **] on [**2157-1-28**] for C diff, UTI
and acute renal failure.
.
Chemotherapy:
[**2157-2-17**] Cycle 1 Gemzar 800mg/m2, week 3 treatment on [**3-3**] was
held due to poor PS.
[**2157-3-11**] Cycle 2 Gemzar 800mg/m2
[**2157-3-25**] 2u pRBC tx [**Hospital1 **]
[**2157-4-7**] Cycle 3 week 1 Gemzar 800mg/m2
[**2157-4-14**] Cycle 3 week 2 Gemzar 800mg/m2
[**2157-4-21**] Cycle 3 week 3 Gem 800 mg/m2, 25% dose reduction
[**2157-4-21**] 2u pRBC tx [**Hospital1 **]
[**2157-5-12**] Cycle 4 week 1-delayed by one week due to diarrhea,
elevated Cr and fatigue
[**2157-5-19**] Cycle 4 Week 2 Gemzar 800mg/m2
[**Date range (1) 29228**] Admitted to [**Hospital1 18**] for chemotherapy induced anemia,
transfused 3 units PRBCs, diagnosed with left popliteal DVT,
declines anticoagulation
[**2157-6-9**] Cycle 5 Week 1 Gemzar 800mg/m2-start 2 weeks on/ 1 week
off
[**2157-6-23**] 2u pRBC tx [**Hospital1 **]
.
- History of DVT ([**2157-5-29**]) on LENI at [**Hospital1 18**]
- Clostridium difficile colitis as above
- Stage III chronic kidney disease (baseline Cr 1.7)
- Diabetes mellitus type 2
- Hypertension
- Hyperlipidemia
- Gastroesophageal reflux disease
- Diverticulosis with recurrent lower GI bleeding, etiology has
been unclear despite workup but presumed diverticular.
- Renal Stone: Left staghorn calculus
- Depression, which is longstanding and difficult to treat.
- Degenerative joint disease
- Gout


Social History:
Patient lives alone in [**Location (un) 86**], and relies on her sister for
needed support.  She is independent, and cares for herself
without any assistance.  There is no recent ETOH use, no tobacco
use (she quit smoking 25 yrs ago), no illicit drug use.

Family History:
Sister with breast cancer, diagnosed at age 58.

Physical Exam:
Adm PE:

General: obese woman, lying in bed, in mild distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to appreciate due to body habitus
Lungs: Diffuse expiratory wheezes, crackles at both bases
CV: Regular and tachycardic, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, distended, well-healed scar, left LLQ with
subcutaneous edema, no rebound tenderness or guarding, no
organomegaly
GU: Foley draining dark fluid
Ext: warm, venous stasis changes on right shin, with 2+ edema up
to the knee, left leg with surgical scar at knee, in airboot,
intact PD pulses

Discharge PE:
97.6  140/86  87  18  97% 2L


Pertinent Results:
1. Labs in admission:
[**2157-8-1**] 11:30AM BLOOD WBC-9.2 RBC-3.72*# Hgb-12.6# Hct-40.5#
MCV-109* MCH-33.9* MCHC-31.1 RDW-23.3* Plt Ct-467*
[**2157-8-1**] 11:30AM BLOOD PT-14.1* PTT-29.2 INR(PT)-1.2*
[**2157-8-1**] 10:00PM BLOOD PT-18.5* PTT-150* INR(PT)-1.7*
[**2157-8-1**] 11:30AM BLOOD Glucose-112* UreaN-23* Creat-1.4* Na-140
K-4.7 Cl-110* HCO3-23 AnGap-12
[**2157-8-1**] 11:30AM BLOOD ALT-11 AST-41* LD(LDH)-308* CK(CPK)-39
AlkPhos-334* TotBili-0.3
[**2157-8-1**] 11:30AM BLOOD CK-MB-3 proBNP-7400*
[**2157-8-1**] 11:30AM BLOOD cTropnT-0.08*
[**2157-8-1**] 10:00PM BLOOD CK-MB-3 cTropnT-0.07*
[**2157-8-1**] 11:30AM BLOOD Albumin-1.9* Calcium-8.1* Phos-4.1 Mg-1.9
[**2157-8-1**] 12:32PM BLOOD Lactate-1.5
.
2. Labs on discharge:
- CA [**65**]-9 ******
.
3. Micro:
[**2157-8-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-POSITIVE {CLOSTRIDIUM DIFFICILE} INPATIENT
[**2157-8-11**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2157-8-5**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2157-8-1**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-Negative
[**2157-8-1**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2157-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2157-8-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2157-8-1**] URINE URINE CULTURE-FINAL {YEAST, PROBABLE
ENTEROCOCCUS} EMERGENCY [**Hospital1 **]

4. Imaging/diagnostics:
- CTA chest ([**2157-8-1**]): 1. Acute PE involving segmental lower
lobe pulmonary arteries. 2. Moderate pericardial effusion with
possible tamponade given flattening of the interventricular
septum. Correlate clinically. 3. Bilateral pleural effusions,
lower lobe atelectasis and ground-glass alveolar opacities
suggesting mild pulmonary edema.
4. Rib lesions as detailed, most focal at the 7th right
posterior rib, ??
metastasis.
.
- CT head ([**2157-8-1**]): No acute intracranial process.
.
- Echocardiogram ([**2157-8-2**]): The left atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is a
very small pericardial effusion. There is significant,
accentuated respiratory variation in mitral/tricuspid valve
inflows, likely secondary to a sizeable *pleural* effusion.
IMPRESSION: Very small pericaridial effusion without tamponade
physiology. Mild right ventricular systolic dysfunction.
Preserved global and regional left ventricular systolic
function.  Compared with the prior study (images reviewed) of
[**2157-7-18**], right ventricle is slightly hypokinetic. Pleural
effusion is new. The other findings, including a very small
pericardial effusion, are similar.

[**2157-8-5**] left femur xray: Atherosclerotic vascular
calcifications. Status post ORIF of the left femur with
retrograde intramedullary nail and interlocking screws. The
hardware is intact. No evidence for hardware loosening or
osteolysis. Again seen is a spiral distal femoral diaphysis
fracture with improved anatomic alignment. No significant
healing. Degenerative changes of the left hip and left knee, not
significantly changed.

[**2157-8-7**] CXR: Left-sided PICC line with tip in the SVC is again
seen. The heart continues to be moderately enlarged. There is
pulmonary vascular
redistribution with perihilar haze and ill-defined vasculature
consistent with CHF. There is a small left effusion and volume
loss in both lower lungs.  Compared to the prior study, the CHF
appears worse.

[**2157-8-9**] CXR: Radiographically there is no indication of
deterioration relative to [**8-7**], in fact lung volumes have
improved. There is still substantial atelectasis at both lung
bases and a small left pleural effusion. Heart is at least
mildly enlarged, but there is no pulmonary edema and vascular
congestion is minimal.  There may have been pulmonary edema
previously. There is none today. No pneumothorax. Left PICC line
can be traced as far as the mid-to-low SVC.

[**2157-8-18**] TEE Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
descending thoracic aorta and aortic arch to 35 cm from the
incisors. There are three aortic valve leaflets. The aortic
valve leaflets are moderately thickened. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is a trivial/physiologic pericardial
effusion.

IMPRESSION: No evidence of spontaneous echo contrast or
intracardiac thrombus. Simple atheroma in the aortic arch and
descending thoracic aorta.

Anticoagulation:
         INR                   Warfarin dose
7/4       3                    4
[**8-16**]       3.3                  3
[**8-17**]       3.8 (am)- 4.7 (pm)   [Vitamin K 1 mg po x1]
[**8-18**]       3                    pending

Discharge labs:
WBC 5.9  Hgb 11.1  HCT 34.9  PLT 308
Na 141 K 3.7  Cl 109  HCO3 25  BUN 18  Cr 1.5  Glu 63

TSH 12
CA19-9 8

Brief Hospital Course:
74 yo F with PMH significant for pancreatic CA s/p Whipple's
procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C.
diff and UTI, and recent left femur fracture, presented with
shortness of breath and tachycardia, found to have pulmonary
embolism and atrial flutter with RVR leading to hypotension
requiring transfer to the ICU.
.
# Respiratory distress: In part due to fluid overload.  She was
found to have pleural effusions and paricardial effusion (no
tampanade).  She required 2-3 days of 25% albumin followed by
high dose lasix which she responded to, and on [**8-10**] she began to
diurese well on her own. Her dyspnea and oxygen requirment
continued to improve with this diuresis, and was 1.7L negative
without lasix for 24 hours as of 8am [**2157-8-12**].  She was
subsequently transferred to the floor where her lasix was
restarted with goal of 1 liter negative per day.  Her lasix was
continued on the floor with ongoing improvement. Her lasix may
need further dose titration for response.

# Pulmonary embolism: CTA showed right basal segmental PE with ?
left segmental PE, which corrolates to her presenting symptoms
of dyspnea and tachycardia. Patient had been on prophylaxic
doses of lovenox after previous hospitalization.  She had a
small pericardial effusion on CTA but no tamponade physiology on
echocardiogram or pulsus paradoxus (8mmHg -> 8mmHg) exam.
Patient started on heparin gtt and warfarin bridge initiated.
Pt's INR had become supratherapeutic, likely d/t interaction
with amiodarone. Pt received 1 mg po Vit K evening of [**2157-8-17**] to
avoid supratherapeutic INR while undergoing DCCV.  Note that
Amiodarone dose is being reduced again at discharge, which will
likely affect coumadin dosing/INR response. Please see results
section for recent INR's and corresponding warfarin dosing. Her
INR will need to be monitored very closely, especially given
changing amiodarone dosing.

# Aflutter with RVR/Hypotension: On admission, HR >130 with sBP
80-90s. Received adenosine challenge and then IV
diltiazem/diltiazem gtt treatment in the ED with poor response.
Attempted to rate control with esmolol gtt but blood pressure
did not tolerate it. Loaded with IV amiodarone and then
transitioned to po amiodarone, and oral diltiazem which was
subsequently discontinued.  Despite amiodarone, she remained in
atrial flutter with sustained HR approx 100.  She therefore
underwent TEE / DC cardioversion, with return to sinus rhythm.
Her amiodarone dose was reduced at time of discharge per
Cardiology recommendations.  TSH was checked and returned at 12.
 Unclear if this represents true hypothyroidism vs euthyroid
sick.  Recommend repeat TSH as pt continues to improve from her
current illness.

# Urinary tract infection: Urinalysis on admission was grossly
positive. Urine culture showed yeast and and 3000 colony count
of enterococcous.  Patient treated with ciprofloxacin 500 mg po
q12hr for 5 days.  Her UA was persistently elevated with
leukocytes.  Patient was insistent that foley not be
discontinued, so her foley was changed on [**8-10**].  Given lack of
fever or WBC, the decision was made to wait until urine culture
resulted before starting antibiotics despite a UA with
persistent pyuria. Subsequent urine culture grew 10k-100k yeast,
which given her absece of symptoms, dd not require further
treatment at this time. Her foley was attempted to be dc'd on
[**2157-8-18**], however pt refused, and will need to be discontinued at
rehab.

# [**Last Name (un) **]: Likely pre-renal secondary to poor forward flow in the
setting of afib with RVR and volume overload.Her creatinine
peaked at 2.3, five days after contrast load.  She required [**3-17**]
days of 25% albumin followed by high dose lasix (as recommended
by nephrology) which she responded to, and on [**8-10**] she began to
diurese well on her own.  She was 1.7L negative without lasix
for 24 hours as of 8am [**2157-8-12**].  Her Cr improved to 1.5 by the
time of discharge.

# Anasarca/Edema
# Severe malnutrition
Pt was treated with IV lasix during this admission to treat
severe diffuse edema and whole body fluid overload. Her lasix
was converted from IV to po, and may need further titration as
an outpatient. Treatment should also focus on nutrition to
improve hypoalbuminemia.

# C. diff colitis: C. diff toxin positive in [**6-22**] and has long
history of C. diff colitis since Whipple procedure in [**2156**].  She
was supposed to complete a 2-week course of Metronidazole 500 mg
po q8hr on during admission.  This was extended given her
treatment for suspected UTI as above.  Despite treatment with po
flagyl, she began to develop severe diarrhea, and c-diff tox
screen turned positive (negative earlier in the admission). She
was changed to po vancomycin, and her diarrhea improved.  She
will need to complete at least 2 weeks of po vancomycin.

# Type 2 Diabetes:
Pt was treated with Lantus and sliding scale insulin during this
admission. Please see sliding scale provided.

# Left femur fracture on previous admission:  She was seen by
orthopaedics who removed sutures/staples.  They recommended
touch-down weight bearing for at least 6wks post-op.  Pt is
touch down weight bearing until [**2157-8-27**].  She will need ongoing
inpatient physical therapy.

# Pancreatic cancer: Followed by Atrius oncologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 349**] who followed during the admission. CA [**65**]-9 rechecked
and was normal at 8.


Medications on Admission:
1. aspirin 81 mg po qd
2. bupropion HCl 450 mg Tablet Extended Release PO QAM
3. docusate sodium 100 mg PO BID
4. insulin Insulin SC Sliding Scale
5. insulin glargine 22 units qhs
6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) PO TID
7. losartan 50 mg PO BID
8. multivitamin PO DAILY
9. simvastatin 40 mg PO DAILY
10. Flagyl 500 mg PO q8hr (planned for [**2157-7-20**] - [**2157-8-2**])
11. senna 8.6 mg PO BID prn constipation
12. bisacodyl 10 mg PO DAILY (Daily) prn constipation
13. oxycodone 10 mg PO Q3H
14. Tylenol Extra Strength 500 mg PO TID
15. Lovenox 40 mg/0.4 mL 1 syringe qd
16. lorazepam 0.5 mg PO Q8H prn for anxiety.
17. calcium carbonate 200 mg calcium (500 mg) Tablet PO QID (4
times a day) prn for heart burn.

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. bupropion HCl 150 mg Tablet Extended Release Sig: Three (3)
Tablet Extended Release PO QAM (once a day (in the morning)).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for heart burn.
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
11. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day.

12. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 10 days: Please note that pt did not respond to po
flagyl.
13. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. Coumadin 3 mg Tablet Sig: One (1) Tablet PO q daily at 1600:
Please follow INR closely and titrate as needed.
15. Lantus 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous at bedtime.
16. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous QACHS: As per sliding scale provided.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]

Discharge Diagnosis:
# Pulmonary embolism
# Atrial flutter
# C-diff colitis
# Anasarca/Edema
# Severe malnutrition
# Acute renal failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted with a fast heart rate and were found to have
a new pulmomary embolism as well as a heart rhythm called atrial
flutter. The pulmonary embolism (=blood clot in lung) was
treated with heparin and transitioned to coumadin. The fast
heart rate did not respond well to several medications but was
ultimately controlled with electric cardioversion. You'll need
to continue on both of these medications.  Your INR will need to
be followed closely.

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2157-12-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other pulmonary embolism and infarction,Other severe protein-calorie malnutrition,Atrial flutter,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Ulcer of other part of lower limb,Body Mass Index 40.0-44.9, adult,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Aftercare for healing traumatic fracture of hip'}


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, tachycardia

PRESENT ILLNESS: 74 yo F with PMH significant for pancreatic CA s/p Whipple's
procedure and chemotherapy, HTN, HLD, CKD, DM 2, recurrent C.
diff and UTI, and recent left femur fracture, presents with
shortness of breath and tachycardia, found to have pulmonary
embolism and atrial flutter with RVR.
.
Patient reports that she was experiencing shortness of breath
this AM at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] and was noted to be tachypneic up to
the 30s. Denied chest pain, chest pressure, diaphoresis,
vomiting, syncope. Otherwise, reports diarrhea from C. diff,
increased upper extremity edema over the past 2 days, and
worsening wheeze.
.
Of note, patient was found to have a non-occlusive left
popliteal DVT on LENI in [**2157-5-29**]. Lovenox and IVC filter were
recommended and patient declined both. On [**2157-7-16**], she syncopized
and sustained a fall from standing height at rehab, resulting in
left oblique displaced comminuted midshaft femur fracture. This
was repaired at [**Hospital1 18**] on [**2157-7-20**] when she underwent a retrograde
femoral nail for left femur fracture. Post-operatively, patient
was discharged on prophylaxis dose of lovenox 40 mg/0.4 ml sc
qd.
.
Two day prior to admission, patient noted increased swelling in
her upper extemities. Also reports having a repeat LENI done of
the left leg which showed disappearance of the previously noted
DVT.
.
In the ED, initial VS were 98.2 141 126/87 24 98% 4L Nasal
Cannula. EKG showed A-flutter and she was given an adenosine
challenge. Received IV diltiazem (5 mg x 3) and then diltiazem
gtt, which was stopped after the CTA showed PE. CT head was
performed to ruled out metastasis which was negative. She was
guaiac negative and started on heparin gtt. Labs were notable
for BNP 7400, troponin 0.08, Cr 1.4 (baseline 1.7), positive UA,
and patient was given vancomycin + zosyn. Per report, bedside
echo did not show RV collapse. On transfer, VS were HR 141 BP
109/71 RR 16 O2sat 97% 3L (NC).
.
On the floor, patient was tachypneic and in slight distress.
Denied chest pain however does report wheezing and shortness of
breath.

MEDICAL HISTORY: - Pancreatitis in [**2156-3-15**] at [**Hospital1 112**]. MRI/MRCP on [**2156-9-29**]
showed a 2 cm cystic mass of the pancreatic head with
obstruction of the pancreatic and bile ducts. She underwent ERCP

MEDICATION ON ADMISSION: 1. aspirin 81 mg po qd
2. bupropion HCl 450 mg Tablet Extended Release PO QAM
3. docusate sodium 100 mg PO BID
4. insulin Insulin SC Sliding Scale
5. insulin glargine 22 units qhs
6. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) PO TID
7. losartan 50 mg PO BID
8. multivitamin PO DAILY
9. simvastatin 40 mg PO DAILY
10. Flagyl 500 mg PO q8hr (planned for [**2157-7-20**] - [**2157-8-2**])
11. senna 8.6 mg PO BID prn constipation
12. bisacodyl 10 mg PO DAILY (Daily) prn constipation
13. oxycodone 10 mg PO Q3H
14. Tylenol Extra Strength 500 mg PO TID
15. Lovenox 40 mg/0.4 mL 1 syringe qd
16. lorazepam 0.5 mg PO Q8H prn for anxiety.
17. calcium carbonate 200 mg calcium (500 mg) Tablet PO QID (4
times a day) prn for heart burn.

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Morphine / Erythromycin Base /
Desipramine / Ace Inhibitors / Codeine / Nifedipine

PHYSICAL EXAM: Adm PE:

FAMILY HISTORY: Sister with breast cancer, diagnosed at age 58.

SOCIAL HISTORY: Patient lives alone in [**Location (un) 86**], and relies on her sister for
needed support.  She is independent, and cares for herself
without any assistance.  There is no recent ETOH use, no tobacco
use (she quit smoking 25 yrs ago), no illicit drug use. 

### Response:
{'Other pulmonary embolism and infarction,Other severe protein-calorie malnutrition,Atrial flutter,Intestinal infection due to Clostridium difficile,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Ulcer of other part of lower limb,Body Mass Index 40.0-44.9, adult,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Diverticulosis of colon (without mention of hemorrhage),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Aftercare for healing traumatic fracture of hip'}
