CHIEF COMPLAINT: Respiratory failure
.

PRESENT ILLNESS: 70 yo woman with h/o CAD, CABG, last DES [**1-17**], IDDM, CKD, CHF
on lasix here from [**Hospital3 4107**] with R sided PNA, NSTEMI. She
reports chest pain, typical for her angina but resistent to SLNG
(5-6 tabs) over the last 5 days (longer duration than normal).
She also c/o dizziness/lightheadedness, nausea/vomitting
(bilious, NB) for the past 2 days, with diarrhea yesterday
(watery, non-bloody, no mucous, but black at baseline given
iron), with no abdominal pain. She notes fever to 102 at home
yesterday. She denies ill contacts, travel, exotic foods. She
does not normally have diarrhea but sometimes can get n/v with
her chest pain. She describes the chest pain as sharp, rated
[**8-22**] yesterday, currently very dull. She notes being seen at [**Hospital1 2177**]
and [**Hospital **] hosp over the past 5 days and told she had
musculoskeletal chest pain. She denied cough to me but did
endorse a feeling of wheezing. She has home oxygen only for
anginal relief and O2 sat monitoring (baseline 95-96% on RA) but
noted decreased O2 sat yesterday to 70's on RA. She was seen at
[**Hospital1 **] [**6-17**], T 101.2 HR 96 RR 18 BP 124/96 Sat 95% NRB, CK 171,
Trop 1.67, WBC 16.3, (N 88, L 5). She was found on CXR with
'right lung white out' and NSTEMI. She was given levofloxacin
500mg iv, compazine iv, 0.5mg ativan, zofran, 1 gm tylenol,
aspirin 325mg, 1" nitro paste.
.
She was then transferred here. VS on arrival T 101, HR 92 BP
158/85, RR 18 Sat 85% on RA. She was given 2.5mg iv metoprolol,
1L NS, 4 gm mag. Her ECG was similar to [**Hospital1 **], but trop
continued to rise. She was started on heparin gtt. Stool guaiac
negative here.
.
ROS: wt stable, no increased swelling, no HA, chronic
(unchanged) photphobia, no neck stiffness, no congestion, denies
cough to me, no orhtopnea, denies palpitation, sore throat,
dysuria, hematuria, rash, + myalgias and chronic joint pain.

MEDICAL HISTORY: -CAD: s/p CABG, last DES 12/05 per her, with unstable angina
(comes and goes at rest), Dr. [**Last Name (STitle) 58088**] called, cardiologist at
[**Hospital1 2177**], s/p CABG with LIMa, SVG x2, cath x2, one complicated by LAD
disection, no further anatomical intervtion for improvement, she
does go for outpatient counterpulasion treatments for treatment
of her CAD/CHF
-IDDM: insulin x22 years, A1C 9 last, s/p B toe nail removal [**3-16**]
DM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis: osteo ? hands, knees
-Le edema
-vertigo
-PVD

MEDICATION ON ADMISSION: imdur 240mg daily
toprol xl 200 [**Hospital1 **]
plavix 75mg daily
aspirin 325mg daily
SLNG prn
ranexa 500mg [**Hospital1 **]
norvasc 10 po daily
clonidine 0.3mg po bid
levoxyl 75mcg daily
protonix 40 daily
lasix 120mg qam 80mg qpm
mvi
lipitor 80 daily
zetia 10 daily
cilostazol 100mg qam 50 qpm
lantus: 22u qhs
iron 325mg daily
celexa 20 daily
ativan 0.5mg q4 prn
meclizine 25mg daily
colace 100mg [**Hospital1 **]
ambien 5mg qhs
nystatin to skin
novolog 4u ac meals
.

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: VS: T 97.9 HR 85 BP 163/80 RR 26 Sat 99% on NRB
GEN: NAD, comfortable, able to speak in full sentences
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, JVP to 8 cm
CV: RRR, nl s1, s2, III/VI HSM at RUSB with radiation to B
carotids, no rubs/gallops
PULM: Diffuse expiratory wheezes, scattered rales, no accessory
muscle use but abdominal paradox in breathing
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL radial and DP; soft tissue
swelling of MCP's B without erythema, warmth, tenderness, B
tenderness to MCP squeeze, bony deformity of DIP's/PIP's.
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
Skin: no rash

FAMILY HISTORY: Mother rheumatic heart dx, father cva.

SOCIAL HISTORY: Widowed, many children live near by, lives with one son (he's
moving), no tobacco, etoh, illicit drug use now or in past.
Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Hematemesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Intestinal infection due to other organism, not elsewhere classified,Constipation, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin
Pneumonia, organism NOS,Subendo infarct, initial,Ac on chr syst hrt fail,Acute kidney failure NOS,Acute respiratry failure,Chronic kidney dis NOS,Hematemesis,Hy kid NOS w cr kid I-IV,Viral enteritis NOS,Constipation NOS,Hypothyroidism NOS,Periph vascular dis NOS,Atrial fibrillation,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,DMII wo cmp nt st uncntr,Long-term use of insulin
Admission Date:  [**2193-6-18**]              Discharge Date:   [**2193-6-28**]

Date of Birth:  [**2123-2-23**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Codeine

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Respiratory failure
.

Major Surgical or Invasive Procedure:
PICC line placement
Endotracheal intubation
.


History of Present Illness:
70 yo woman with h/o CAD, CABG, last DES [**1-17**], IDDM, CKD, CHF
on lasix here from [**Hospital3 4107**] with R sided PNA, NSTEMI. She
reports chest pain, typical for her angina but resistent to SLNG
(5-6 tabs) over the last 5 days (longer duration than normal).
She also c/o dizziness/lightheadedness, nausea/vomitting
(bilious, NB) for the past 2 days, with diarrhea yesterday
(watery, non-bloody, no mucous, but black at baseline given
iron), with no abdominal pain. She notes fever to 102 at home
yesterday. She denies ill contacts, travel, exotic foods. She
does not normally have diarrhea but sometimes can get n/v with
her chest pain. She describes the chest pain as sharp, rated
[**8-22**] yesterday, currently very dull. She notes being seen at [**Hospital1 2177**]
and [**Hospital **] hosp over the past 5 days and told she had
musculoskeletal chest pain. She denied cough to me but did
endorse a feeling of wheezing. She has home oxygen only for
anginal relief and O2 sat monitoring (baseline 95-96% on RA) but
noted decreased O2 sat yesterday to 70's on RA. She was seen at
[**Hospital1 **] [**6-17**], T 101.2 HR 96 RR 18 BP 124/96 Sat 95% NRB, CK 171,
Trop 1.67, WBC 16.3, (N 88, L 5). She was found on CXR with
'right lung white out' and NSTEMI. She was given levofloxacin
500mg iv, compazine iv, 0.5mg ativan, zofran, 1 gm tylenol,
aspirin 325mg, 1" nitro paste.
.
She was then transferred here. VS on arrival T 101, HR 92 BP
158/85, RR 18 Sat 85% on RA. She was given 2.5mg iv metoprolol,
1L NS, 4 gm mag. Her ECG was similar to [**Hospital1 **], but trop
continued to rise. She was started on heparin gtt. Stool guaiac
negative here.
.
ROS: wt stable, no increased swelling, no HA, chronic
(unchanged) photphobia, no neck stiffness, no congestion, denies
cough to me, no orhtopnea, denies palpitation, sore throat,
dysuria, hematuria, rash, + myalgias and chronic joint pain.


Past Medical History:
-CAD: s/p CABG, last DES 12/05 per her, with unstable angina
(comes and goes at rest), Dr. [**Last Name (STitle) 58088**] called, cardiologist at
[**Hospital1 2177**], s/p CABG with LIMa, SVG x2, cath x2, one complicated by LAD
disection, no further anatomical intervtion for improvement, she
does go for outpatient counterpulasion treatments for treatment
of her CAD/CHF
-IDDM: insulin x22 years, A1C 9 last, s/p B toe nail removal [**3-16**]
DM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis: osteo ? hands, knees
-Le edema
-vertigo
-PVD


Social History:
Widowed, many children live near by, lives with one son (he's
moving), no tobacco, etoh, illicit drug use now or in past.

Family History:
Mother rheumatic heart dx, father cva.

Physical Exam:
VS: T 97.9 HR 85 BP 163/80 RR 26 Sat 99% on NRB
GEN: NAD, comfortable, able to speak in full sentences
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, JVP to 8 cm
CV: RRR, nl s1, s2, III/VI HSM at RUSB with radiation to B
carotids, no rubs/gallops
PULM: Diffuse expiratory wheezes, scattered rales, no accessory
muscle use but abdominal paradox in breathing
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL radial and DP; soft tissue
swelling of MCP's B without erythema, warmth, tenderness, B
tenderness to MCP squeeze, bony deformity of DIP's/PIP's.
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
Skin: no rash


Pertinent Results:
PERTINENT LABS:

STUDIES:
CXR [**6-18**]: 1. Focal opacity at right lung base concerning for
pneumonia. 2. Likely mild pulmonary edema. 3. Probable small
bilateral pleural effusions.
.
TTE [**6-18**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the mid- and distal segments of the anterior
wall, and severe hypokinesis/akinesis of the distal [**2-14**] of the
left ventricle, c/w LAD disease. The remaining segments contract
normally (LVEF = 30-35%). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. There are three moderately thickened aortic
valve leaflets. There is mild aortic valve stenosis (area
1.2-1.9cm2). The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction, c/w CAD. Mild calcific aortic stenosis. Moderate
pulmonary hypertension.
.
BILATERAL LENIS [**6-18**]: No deep vein thrombosis identified in
either leg.
.
CXR [**6-20**]: Significant interval improvement in bilateral perihilar
opacities is consistent with resolution of pulmonary edema.
Still present bibasilar consolidations might represent
atelectasis and/or infectious process as well as there is no
significant change in bilateral pleural effusions.
.
CT TORSO [**6-20**]: 1. Cardiomegaly with small bilateral pleural
effusions and mild pulmonary edema. Mild bibasilar atelectasis
vs aspiration.
2. Extensive coronary artery calcification.
3. Normal positioning of lines and tubes.
4. Nonobstructing renal calculus measuring 3 mm in the lower
pole of the right kidney.
5. Extensive mesenteric vascular calcifications and renal
arterial
calcifications.
6. Scoliosis with degenerative changes.
7. Two small pulmonary nodules measuring less than 4mm. One year
follow-up chest CT or comparison with prior outside studies is
recommended.
.
TTE with bubble study [**6-21**]: No obvious intracardiac shunt
detected.
.
CXR [**6-22**]: Combination of bibasilar atelectasis and small right
pleural effusion are unchanged over the past two days. Moderate
cardiomegaly is stable though larger today than yesterday
accompanied by increase in caliber of the central pulmonary
arteries and azygos vein, all of which may be due to interval
extubation rather than cardiac decompensation. Left PIC line
ends in the mid-SVC. No pneumothorax.
.
[**2193-6-17**] WBC-16.8 Hgb-13.6 Hct-39.5 MCV-95  Plt Ct-259
[**2193-6-17**] Neuts-91.6 Lymphs-5.3 Monos-2.8 Eos-0.2 Baso-0.1
[**2193-6-18**] WBC-17.7 Hgb-13.3 Hct-38.4 MCV-95 Plt Ct-282
[**2193-6-25**] WBC-11.1 Hgb-11.5 Hct-33.3 MCV-93 Plt Ct-349
[**2193-6-17**] Glucose-281 UreaN-28 Creat-1.8 Na-138 K-3.6 Cl-101
HCO3-19
[**2193-6-25**] Glucose-202 UreaN-78 Creat-2.7 Na-137 K-3.6 Cl-93
HCO3-33
[**2193-6-17**] CK(CPK)-201 CK-MB-17 MB Indx-8.5
[**2193-6-20**] cTropnT-0.85
[**2193-6-18**] proBNP- >70,000
[**2193-6-18**] ALT-17 AST-44 CK-234 AlkPhos-103 Amylase-17 TBili-0.4
Lipase-11
[**2193-6-25**] ALT-29 AST-35 LDH-248 AlkPhos-100 Amylase-24
TotBili-0.4 Lipase-23
[**2193-6-18**] %HbA1c-8.4
[**2193-6-18**] TSH-2.1
.
[**2193-6-18**] URINALYSIS Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
Blood-SM  Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG RBC-8* WBC-8*
Bacteri-NONE Yeast-NONE Epi-<1 CastHy-6*
[**2193-6-19**] URINE Osmolal-309 UreaN-153 Creat-23 Na-97
.
MICRO:
5/5 BLOOD CX- no growth
[**6-20**] BLOOD CX- pending at time of discharge
[**6-18**] URINE CX- no growth
[**6-19**] URINE CX- no growth
[**6-19**] BAL-
GRAM STAIN (Final [**2193-6-19**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2193-6-21**]):    ~1000/ML
OROPHARYNGEAL FLORA.
[**6-19**] SPUTUM CX-
GRAM STAIN (Final [**2193-6-19**]):
      [**12-7**] PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2193-6-21**]):    NO GROWTH.
[**6-20**] STOOL C DIFF- negative, FECAL CX- negative


Brief Hospital Course:
Ms. [**Known lastname **] is a 70 year-old female with history of CAD, CHF with
EF 30%, HTN, DM2 who presented from an OSH with hypoxic
respiratory failure and NSTEMI. She was initially admitted to
the MICU. She was treated with levofloxacin and vancomycin to
cover for HAP. Cardiology consult was obtained and recommended
medical management as she is not a candidate for
revascularization. BNP was noted to be >70,000. She was diuresed
with IV lasix and is [**Location 10226**]4L. Overnight on [**6-18**] she developed
Afib with RVR to 120-130s and transient desat to 70s on CPAP,
felt to be [**3-16**] hypoxia and pneumonia. Rate controlled with
metoprolol and diltiazem. On [**6-19**] she was electively intubated
for failing CPAP. Trop peaked at 0.82 and heparin gtt was
discontinued on [**6-20**]. Converted back to NSR on [**6-20**]. Started lasix
gtt on [**6-20**] for diuresis. She was successfully extubated on [**6-21**].
On [**6-23**], she was transferred to the medical floor.
.
# Respiratory failure: This was felt to be due to a mixed
picture of CHF +/- PNA on CXR; both improved clinically and on
imaging with antibiotics and diuresis with lasix. She was
elective intubated the day after admission (after a 24h trial of
CPAP failed to improve her respiratory status) and successfully
extubated on hospital day 3. PaO2/FiO2 initially 200-300 - [**Doctor Last Name **].
Low probability PE with Well's criteria. US to assess pleural
effusions [**6-20**] - no appreciable effusions. CT chest without
contrast [**6-20**] - small bilateral pleural effusions and mild
pulmonary edema, mild bibasilar atelectasis vs aspiration.
Sputum culture, mini-BAL - no organisms on gram stain, cultures
pending - potential viral/atypical infection. Vanco was
discontinued given negative cultures. She was quickly weaned off
of oxygen once she reached the medical floor. She completed an
eight-day course of levofloxacin to empirically treat for
health-care associated pneumonia. CXR 2 days prior to discharge
showed resolution of pulmonary edema and infiltrates.
.
# Acute on chronic systolic congestive heart failure: She has an
EF 30-35%, and as above, was felt to be in florid heart failure
on initial presentation. BNP was >70,000 with pulmonary edema on
CXR and hypoxic respiratory failure requiring intubation. Fluid
overload improved with diuresis. Diuresis was complicated by
acute renal failure (cr 1.8-->2.7) so lasix were held on the
medical floor. She remained euvolemic and creatinine returned to
her baseline. She was continued on optimal medical management
with metoprolol, imdur, and hydralazine. She has a reported
allergy to ACEI and [**Last Name (un) **]. Could consider EP evaluation as
outpatient for AICD placement for primary prevention.
.
# NSTEMI/CAD: Suspected to be due to demand in the setting of
hypoxic respiratory failure. Also likely related to her
inability to take her cardiac meds the 2 days prior to her
initial admission to OSH [**3-16**] n/v/d. Patient has been deemed not
a candidate for further revascularization based on cardiac
catheterization reports from [**Hospital1 2177**]. Heparin gtt was discontinued
on [**6-20**] (48 hours since event). She was continued on ASA, plavix,
BB, statin, imdur, ranexa. Medications were titrated to optimal
medical management, with cardiology consult assistance.
.
# Fever/leukocytosis: Either due to PNA or a presumed viral
gastrointestinal process. Bacterial cultures were negative. UA
negative; urine culture negative; blood cultures no growth. LFTs
unremarkable. No diarrhea since admission. She completed an 8
day course Levofloxacin for empiric treatment of PNA or GI
source of infection.
.
# AFib with RVR: Occurred in the setting of PNA/hypoxic
respiratory failure and fluid overload. TSH WNL. CHADS2 score 3.
She was effectively treated with antibiotics and diuresis and
converted to sinus rhythm. Metoprolol was continued for rate
control. No further episodes.
.
# ARF on CRF: Her baseline creatinine is 1.9. On admission her
creatinine was 1.8. As she was diuresed her creatinine rose to
2.7 by the day of transfer to the floor, likely pre-renal ARF.
Lasix was held initially after transfer. Her medications were
renally dosed.
.
# Hypertension: She is on an extensive blood pressure regimen at
home, including imdur, toprol, clonidine, and norvasc. Her
regimen was slowly up-titrated toward her home regimen.
Hydralazine was also added. Clonidine was held.
.
# DM2: Her Diabetes is poorly controlled as an outpatient,
evidenced by her HbA1C of 8.4. She was continued on lantus and a
humalog insulin sliding scale. Her lantus dose was increased to
achieve better control.
.
# Nausea/vomitting/diarrhea: She had 2 days of nausea, vomiting,
and diarrhea associated with fever prior to admission to the
OSH. This was felt likely to represent an infectious (viral)
gastroenteritis. Less likely diabetic gastroparesis. LFTs,
amylase/lipase unremarkable. C diff and stool cultures were
negative. Stool cx negative. These symptoms quickly resolved
after admission, until she had a recurrent episode 1 week into
her admission (see below).
.
# Nausea/vomiting/lightheadedness (second episode)-- Coffee
grounds emesis: On the day following being called out out of the
MICU, the patient complained of lightheadedness and nausea,
exacerbated by movement.  The following day she was unable to
tolerate PO liquids or solids. No diarrhea. Later that day she
developed one episode of small coffee grounds emesis. This
cleared quickly with NG lavage with no evidence of bright red
blood. Felt most likely related to mucosal irritation or small
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] tear from excessive vomiting. EKG was obtained
without ischemic changes. She was orthostatic with SBP
140s-->120s from lying to sitting. PO lasix was held out of
concern that her symptoms were due to being over-diuresed. LFTs,
amylase, and lipase were within normal limits. She was afebrile.
KUB was unremarkable. The patient had been constipated for >1
week. After an aggressive bowel regimen was instituted she
eventually had a large bowel regimen. Her symptoms of nausea and
vomiting quickly resolved and she was able to tolerate POs
again.
.
# PVD: No active issues. Continued her outpatient cilostazol.
.
# Depression: No active issues. She was continued on her
outpatient celexa.
.
# Hypothyroid: No active issues. TSH 2.1. She was continued on
her outpatient levothyroxine dose.
.
# Vertigo/history of Meniere's disease: Takes meclizine at home.
Occasionally this acts up when she is hospitalized. Meclizine
had been held for most of her hospitalization but was re-started
in the setting of her nausea and dizziness, thinking that her
Meniere's disease could be contributing.
.
# Pulmonary nodules: Two small pulmonary nodules measuring less
than 4mm were seen on CT scan. One year follow-up chest CT or
comparison with prior outside studies is recommended.
.


Medications on Admission:
imdur 240mg daily
toprol xl 200 [**Hospital1 **]
plavix 75mg daily
aspirin 325mg daily
SLNG prn
ranexa 500mg [**Hospital1 **]
norvasc 10 po daily
clonidine 0.3mg po bid
levoxyl 75mcg daily
protonix 40 daily
lasix 120mg qam 80mg qpm
mvi
lipitor 80 daily
zetia 10 daily
cilostazol 100mg qam 50 qpm
lantus: 22u qhs
iron 325mg daily
celexa 20 daily
ativan 0.5mg q4 prn
meclizine 25mg daily
colace 100mg [**Hospital1 **]
ambien 5mg qhs
nystatin to skin
novolog 4u ac meals
.

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Cilostazol 50 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
9. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Four (4) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO twice a day.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
14. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q4H (every 4 hours) as needed.
19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
20. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale  Subcutaneous four times a day.
21. Lantus 100 unit/mL Solution Sig: Twenty Four (24) units
Subcutaneous at bedtime.
22. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
23. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day.
24. Novolog 100 unit/mL Solution Sig: Four (4) units
Subcutaneous three times a day: with meals.
25. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed.
26. Lasix 40 mg Tablet Sig: Three (3) Tablet PO qAM.
27. Lasix 40 mg Tablet Sig: Two (2) Tablet PO qPM.
28. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
29. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Primary: NSTEMI, CHF exacerbation, pneumonia
Secondary:
-CAD
-IDDM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis
-Le edema
-vertigo
-PVD
.


Discharge Condition:
Vitals stable. Satting well on RA. Tolerating a regular diet.
.

Discharge Instructions:
You were admitted to the hospital with a heart attack and
worsening of your heart failure, as well as possible pneumonia.
These were treated with antibiotics, heart medications, and
lasix. You also had nausea and vomiting, likely from
constipation.
.
Take all medications as prescribed.
.
If you develop shortness of breath, chest pain, fevers>101,
persistent nausea and vomiting, or other concerning symptoms,
you should return to the nearest ED.
.

Followup Instructions:
You should follow up with your PCP within the next 2 weeks.
[**Last Name (LF) **],[**First Name3 (LF) **] A [**Telephone/Fax (1) 8960**].
.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Hematemesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Intestinal infection due to other organism, not elsewhere classified,Constipation, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}


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: Respiratory failure
.

PRESENT ILLNESS: 70 yo woman with h/o CAD, CABG, last DES [**1-17**], IDDM, CKD, CHF
on lasix here from [**Hospital3 4107**] with R sided PNA, NSTEMI. She
reports chest pain, typical for her angina but resistent to SLNG
(5-6 tabs) over the last 5 days (longer duration than normal).
She also c/o dizziness/lightheadedness, nausea/vomitting
(bilious, NB) for the past 2 days, with diarrhea yesterday
(watery, non-bloody, no mucous, but black at baseline given
iron), with no abdominal pain. She notes fever to 102 at home
yesterday. She denies ill contacts, travel, exotic foods. She
does not normally have diarrhea but sometimes can get n/v with
her chest pain. She describes the chest pain as sharp, rated
[**8-22**] yesterday, currently very dull. She notes being seen at [**Hospital1 2177**]
and [**Hospital **] hosp over the past 5 days and told she had
musculoskeletal chest pain. She denied cough to me but did
endorse a feeling of wheezing. She has home oxygen only for
anginal relief and O2 sat monitoring (baseline 95-96% on RA) but
noted decreased O2 sat yesterday to 70's on RA. She was seen at
[**Hospital1 **] [**6-17**], T 101.2 HR 96 RR 18 BP 124/96 Sat 95% NRB, CK 171,
Trop 1.67, WBC 16.3, (N 88, L 5). She was found on CXR with
'right lung white out' and NSTEMI. She was given levofloxacin
500mg iv, compazine iv, 0.5mg ativan, zofran, 1 gm tylenol,
aspirin 325mg, 1" nitro paste.
.
She was then transferred here. VS on arrival T 101, HR 92 BP
158/85, RR 18 Sat 85% on RA. She was given 2.5mg iv metoprolol,
1L NS, 4 gm mag. Her ECG was similar to [**Hospital1 **], but trop
continued to rise. She was started on heparin gtt. Stool guaiac
negative here.
.
ROS: wt stable, no increased swelling, no HA, chronic
(unchanged) photphobia, no neck stiffness, no congestion, denies
cough to me, no orhtopnea, denies palpitation, sore throat,
dysuria, hematuria, rash, + myalgias and chronic joint pain.

MEDICAL HISTORY: -CAD: s/p CABG, last DES 12/05 per her, with unstable angina
(comes and goes at rest), Dr. [**Last Name (STitle) 58088**] called, cardiologist at
[**Hospital1 2177**], s/p CABG with LIMa, SVG x2, cath x2, one complicated by LAD
disection, no further anatomical intervtion for improvement, she
does go for outpatient counterpulasion treatments for treatment
of her CAD/CHF
-IDDM: insulin x22 years, A1C 9 last, s/p B toe nail removal [**3-16**]
DM
-CKD (baseline crt 1.9)
-CHF
-low back surgery
-arthiritis: osteo ? hands, knees
-Le edema
-vertigo
-PVD

MEDICATION ON ADMISSION: imdur 240mg daily
toprol xl 200 [**Hospital1 **]
plavix 75mg daily
aspirin 325mg daily
SLNG prn
ranexa 500mg [**Hospital1 **]
norvasc 10 po daily
clonidine 0.3mg po bid
levoxyl 75mcg daily
protonix 40 daily
lasix 120mg qam 80mg qpm
mvi
lipitor 80 daily
zetia 10 daily
cilostazol 100mg qam 50 qpm
lantus: 22u qhs
iron 325mg daily
celexa 20 daily
ativan 0.5mg q4 prn
meclizine 25mg daily
colace 100mg [**Hospital1 **]
ambien 5mg qhs
nystatin to skin
novolog 4u ac meals
.

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: VS: T 97.9 HR 85 BP 163/80 RR 26 Sat 99% on NRB
GEN: NAD, comfortable, able to speak in full sentences
HEENT: AT, NC, PERRLA, EOMI, no conjuctival injection,
anicteric, OP clear, MMM
Neck: supple, no LAD, JVP to 8 cm
CV: RRR, nl s1, s2, III/VI HSM at RUSB with radiation to B
carotids, no rubs/gallops
PULM: Diffuse expiratory wheezes, scattered rales, no accessory
muscle use but abdominal paradox in breathing
ABD: soft, NT, ND, + BS, no HSM
EXT: warm, dry, +2 distal pulses BL radial and DP; soft tissue
swelling of MCP's B without erythema, warmth, tenderness, B
tenderness to MCP squeeze, bony deformity of DIP's/PIP's.
NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength
throughout. No sensory deficits to light touch appreciated.
Skin: no rash

FAMILY HISTORY: Mother rheumatic heart dx, father cva.

SOCIAL HISTORY: Widowed, many children live near by, lives with one son (he's
moving), no tobacco, etoh, illicit drug use now or in past. 

### Response:
{'Pneumonia, organism unspecified,Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Hematemesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Intestinal infection due to other organism, not elsewhere classified,Constipation, unspecified,Unspecified acquired hypothyroidism,Peripheral vascular disease, unspecified,Atrial fibrillation,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin'}
