CHIEF COMPLAINT: AMS, shortness of breath

PRESENT ILLNESS: 88yo F PMhx CHF, HTN presenting w AMS in the setting of a fall.
1d prior to presentation, patient was getting out of bathtub
when she slipped; this was an observed fall by the patient's
VNA; no head strike, no LOC. Patient reports she initially felt
fine, and refused to go to the ED at that time. On day of
admisison, family reported that patient sounded confused over
the phone, acting "sleepy". Patient denied fevers, chills,
nausea/vomitting, cough, motor/sensory deficits; reported pain
over her L ribs from her fall. Patient's family brought her to
the ED for further evaluation.
.
On presentation to the ED, initial vital signs were 99.4 60
117/45 20 92%. Exam was remarkable for hematoma over L rib,
atraumatic head, mild abdominal tenderness; labs were
significant or WBC 5.9, Hct 34.7, platelets 122, ALT 44, AST 80,
BNP 3244, Cr 1.9, UA wnl, trop .03; CXR unremarkable, RUQ u/s
unremarkable, CT unremarkable; while in the ED patient spiked
fever to 101.3. Blood cx were sent and patient was given
vancomycin/zosyn and was admitted to medicine for further
management. At time of transfer, vital signs were 98.9 61 142/63
20 100%3L.
.
On arrival to the floor vital signs were 99.9 160/75 59 18
93%2L. On further questioning patient reported increased SOB and
constipation; denied headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, , BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. CAD - 3 Vessel, medically managed
2. Severe aortic stenosis. [**Location (un) 109**] of 0.8-1.0 cm2, AV gradient of
60-33 mmHg per recent echocardiogram performed in 03/[**2172**]. AVR
was considered but the pt refused surgery, and preferred to
continue on medical therapy.
3. paroxysmal atrial fibrillation, s/p pacemaker placement in
[**2158**] for tachy-brady syndrome, followed by generator change in
[**2169**]. Amiodarone was re-initiated in [**2171-7-10**] d/t increased
frequency of AF.
4. HTN
5. diastolic CHF
6. Hypothyroidism
7. Chronic lung nodules

MEDICATION ON ADMISSION: ASA 81mg daily
Amiodarone 200mg daily
carvedilol 12.5mg [**Hospital1 **]
simva 20mg daily
diovan 80mg daily
meclizine 12.5mg [**Hospital1 **]
levothyroxine 50mcg daily
colace [**Hospital1 **]
senna [**Hospital1 **]
torsemide 40mg [**Hospital1 **]

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ADMISSION EXAM:
VS: 99.9 160/75 59 18 93%2L
GENERAL: NAD, comfortable
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
NECK: Supple, 6cm JVD, no LAD.
HEART: RRR, no MRG
LUNGS: Inspiratory crackles bilaterally, decreased breathsounds
at R base
ABDOMEN: Soft/NT/ND, suprapubic fullness, no rebound/guarding
EXTREMITIES: WWP, trace edema to ankle, 2+ DP/PT/radial pulses
NEURO: AOx3, CNs II-XII grossly intact, muscle strength 5/5 x4
extremities, gait not observed
.
DISCHARGE EXAM:
 Tm 99.6 Tc 99.5 131/41 59 20 95% 2L
General: Alert, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral scattered crackles, worse at bases
CV: RRR, 3/6 systolic murmur radiates to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining transparent urine
Ext: warm, well perfused, 2+ pulses, no edema.  L foot/ankle
swollen with slight erythema, tender to touch over toes

FAMILY HISTORY: mult family members w +CAD

SOCIAL HISTORY: Patient lives alone in [**Location (un) 583**], with daughter [**Name (NI) **] (health care
proxy)
living nearby. Patient has help for cleaning and bathing,
does some cooking, daughter does shopping. Walks with walker.
Weekly VNA services. No h/o tobacco, ETOH.
Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Unspecified septicemia,Sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aortic valve disorders,Acute gouty arthropathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Constipation, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Do not resuscitate status,History of fall,Thrombocytopenia, unspecified
Ac on chr diast hrt fail,Pneumonia, organism NOS,Septicemia NOS,Sepsis,Acute respiratry failure,Acute kidney failure NOS,Aortic valve disorder,Acute gouty arthropathy,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Constipation NOS,Crnry athrscl natve vssl,Hypothyroidism NOS,Do not resusctate status,Personal history of fall,Thrombocytopenia NOS
Admission Date:  [**2173-8-14**]              Discharge Date:   [**2173-8-26**]


Service: MEDICINE

Allergies:
Morphine Sulfate

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

Major Surgical or Invasive Procedure:
PICC line


History of Present Illness:
88yo F PMhx CHF, HTN presenting w AMS in the setting of a fall.
1d prior to presentation, patient was getting out of bathtub
when she slipped; this was an observed fall by the patient's
VNA; no head strike, no LOC. Patient reports she initially felt
fine, and refused to go to the ED at that time. On day of
admisison, family reported that patient sounded confused over
the phone, acting "sleepy". Patient denied fevers, chills,
nausea/vomitting, cough, motor/sensory deficits; reported pain
over her L ribs from her fall. Patient's family brought her to
the ED for further evaluation.
.
On presentation to the ED, initial vital signs were 99.4 60
117/45 20 92%. Exam was remarkable for hematoma over L rib,
atraumatic head, mild abdominal tenderness; labs were
significant or WBC 5.9, Hct 34.7, platelets 122, ALT 44, AST 80,
BNP 3244, Cr 1.9, UA wnl, trop .03; CXR unremarkable, RUQ u/s
unremarkable, CT unremarkable; while in the ED patient spiked
fever to 101.3. Blood cx were sent and patient was given
vancomycin/zosyn and was admitted to medicine for further
management. At time of transfer, vital signs were 98.9 61 142/63
20 100%3L.
.
On arrival to the floor vital signs were 99.9 160/75 59 18
93%2L. On further questioning patient reported increased SOB and
constipation; denied headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, , BRBPR, melena, hematochezia, dysuria, hematuria.


Past Medical History:
1. CAD - 3 Vessel, medically managed
2. Severe aortic stenosis. [**Location (un) 109**] of 0.8-1.0 cm2, AV gradient of
60-33 mmHg per recent echocardiogram performed in 03/[**2172**]. AVR
was considered but the pt refused surgery, and preferred to
continue on medical therapy.
3. paroxysmal atrial fibrillation, s/p pacemaker placement in
[**2158**] for tachy-brady syndrome, followed by generator change in
[**2169**]. Amiodarone was re-initiated in [**2171-7-10**] d/t increased
frequency of AF.
4. HTN
5. diastolic CHF
6. Hypothyroidism
7. Chronic lung nodules


Social History:
Patient lives alone in [**Location (un) 583**], with daughter [**Name (NI) **] (health care
proxy)
living nearby. Patient has help for cleaning and bathing,
does some cooking, daughter does shopping. Walks with walker.
Weekly VNA services. No h/o tobacco, ETOH.


Family History:
mult family members w +CAD

Physical Exam:
ADMISSION EXAM:
VS: 99.9 160/75 59 18 93%2L
GENERAL: NAD, comfortable
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
NECK: Supple, 6cm JVD, no LAD.
HEART: RRR, no MRG
LUNGS: Inspiratory crackles bilaterally, decreased breathsounds
at R base
ABDOMEN: Soft/NT/ND, suprapubic fullness, no rebound/guarding
EXTREMITIES: WWP, trace edema to ankle, 2+ DP/PT/radial pulses
NEURO: AOx3, CNs II-XII grossly intact, muscle strength 5/5 x4
extremities, gait not observed
.
DISCHARGE EXAM:
 Tm 99.6 Tc 99.5 131/41 59 20 95% 2L
General: Alert, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral scattered crackles, worse at bases
CV: RRR, 3/6 systolic murmur radiates to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining transparent urine
Ext: warm, well perfused, 2+ pulses, no edema.  L foot/ankle
swollen with slight erythema, tender to touch over toes


Pertinent Results:
Admission labs:
[**2173-8-14**] 03:18PM BLOOD WBC-5.9 RBC-4.03* Hgb-12.2 Hct-34.7*
MCV-86# MCH-30.3 MCHC-35.2* RDW-14.2 Plt Ct-122*
[**2173-8-14**] 03:18PM BLOOD Neuts-48* Bands-0 Lymphs-43* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2173-8-14**] 03:18PM BLOOD PT-13.8* PTT-23.5 INR(PT)-1.2*
[**2173-8-14**] 03:18PM BLOOD Glucose-104* UreaN-39* Creat-1.9* Na-140
K-5.1 Cl-102 HCO3-24 AnGap-19
[**2173-8-14**] 03:18PM BLOOD ALT-44* AST-80* AlkPhos-75 TotBili-0.6
[**2173-8-14**] 03:18PM BLOOD proBNP-3244*
[**2173-8-14**] 03:18PM BLOOD cTropnT-0.03*
[**2173-8-14**] 03:18PM BLOOD Albumin-3.9 Calcium-8.5 Phos-4.7* Mg-2.5
[**2173-8-14**] 03:26PM BLOOD Lactate-1.8
.
DISCHARGE LABS:
[**2173-8-25**] 05:47AM BLOOD WBC-6.5 RBC-3.48* Hgb-10.7* Hct-30.6*
MCV-88 MCH-30.6 MCHC-34.9 RDW-14.2 Plt Ct-264
[**2173-8-25**] 05:47AM BLOOD Glucose-94 UreaN-23* Creat-1.1 Na-141
K-3.6 Cl-105 HCO3-28 AnGap-12
[**2173-8-25**] 05:47AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1
.
IMAGING:
CXR [**2173-8-14**]
1. Blunting of bilateral costophrenic angles; while could relate
to overlying soft tissue, but trace pleural effusions or pleural
thickening not excluded.
2. Possible minimal interstitial pulmonary edema.
.
Echo [**2173-8-17**]
The left atrium is dilated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to
moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.

Compared with the prior study (images reviewed) of [**2172-3-9**], the
severity of aortic stenosis is similar.
.
BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUND ([**8-19**]): [**Doctor Last Name **]-scale
and Doppler son[**Name (NI) 1417**] of the bilateral common femoral,
superficial femoral, and popliteal veins were obtained.
Evaluation of the calf veins was limited due to patient body
habitus. However, there is normal flow, compressibility, and
augmentation of the above examined veins.
IMPRESSION: No DVT.
.
CHEST CT ([**8-19**]):FINDINGS:
The airways are patent to the segmental level. Mediastinal
lymphadenopathy is longstanding measuring up to 30 x 12 mm in
the right upper posterior
paratracheal station, 11 mm right lower paratracheal station, 12
mm in the AP window. There is mild cardiomegaly. There is severe
calcification of the aortic valve and mitral annulus. There are
also severe/dense atherosclerotic calcifications in all coronary
arteries. Pacemaker leads are in standard position. There is no
pericardial effusion. The aorta is normal in caliber with
moderate calcifications in the ascending aorta and aortic arch.

There are small bilateral nonhemorrhagic pleural effusions.
Multifocal areas of lung consolidation in the upper lobes, left
greater than right, lingula, are most likely infectious in
etiology with a component of pulmonary edema given the fact that
there is mild interlobular septal thickening and ground-glass
opacities in the upper lobes bilaterally. In the lower lobes
bilaterally bibasilar consolidations are associated with loss of
volume in the left lower lobe and small bilateral nonhemorrhagic
pleural effusions.
A calcified small lung nodule in the right lobe, which is
stable.
Other previously described lung nodules are obscured by lung
opacities.
This examination is not tailored for subdiaphragmatic
evaluation. A
subcentimeter hypodense lesion in the right lobe of the liver
(2:45) is
unchanged, too small to be characterized. There is a small
hiatal hernia.
There are no bone findings of malignancy. There is a vertebral
hemangioma in L1.
IMPRESSION:
Multifocal pneumonia, small bilateral pleural effusion. There is
also a
minimal component of interstitial edema.


Brief Hospital Course:
88yo F PMHx CHF, HTN presented initially with pneumonia, s/p
fall with fevers to 103 and worsening pulmonary edema, required
ICU admission for BiPap. Fared well with broad spectrum
antibiotics and diuresis.
.
ACTIVE ISSUES:
.
Pneumonia: Pt was initially started on ceftriaxone and
doxycycline for presumed treatment for CAP given that patient is
on amiodarone and concern for prolonged QT.  She was stable on
the floor until hospital day 2, when she developed acute
shortness of breath, tachypnea, and increase in O2 requirement
from 96% on 3L -> 90% on 3L.  She received Lasix IV, nitropaste,
and was placed on facemask with no improvement in her
oxygenation.  She was transferred to the MICU for initiation of
BiPap.  In the ICU, her antibiotic coverage was broadened to
vancomycin, ceftriaxone, and doxycycline.  Because she continued
to spike fevers, she was switched to vancomycin, Zosyn and
Cipro. CT chest was done given hx of lung nodules and showed
multifocal pneumonia, small bilateral pleural effusion and a
minimal component of interstitial edema.  She has remained
afebrile since starting on vanc/zosyn/cipro and will be
discharged to rehab to complete a 14 day course, last day [**9-2**].

.
# Acute on chronic diastolic heart failure: Pt has known history
of severe diastolic heart failure with critical AS.  She was
being managed with Lasix 40mg IV BID while in the hospital,
however on hospital day 2 pt developed increasing oxygen
requirement, and became tachypneic, likely due to flash
pulmonary edema.  She was treated with IV Lasix, nitropaste and
morphine, however her O2 sats remained in mid 80s so she was
transferred to the MICU for BiPap.  During her MICU stay, she
had a few episodes of hypotension which responded to small fluid
boluses (500cc). Echo was repeated, and  aortic stenosis was
similar. On hospital day 4, she developed another episode of
hypoxia, this time with good response to IV Lasix.  She was
resumed on her home dose of torsemide 40mg PO BID, with Lasix
PRN. BP remained stable and she was able to tolerate diuresis.
Her oxygen saturation remained stable at mid 90s on 2L.  She did
have LENIs done to rule out PE as possible source of acute
hypoxia, but these were negative for DVT.  Her oxygen saturation
and fluid status was complicated during this stay with
superimposed pulmonary edema upon her pneumonia in the setting
of critical AS.
.
# Gout: Pt developed acute gouty attack during hospitalization,
like secondary to diuresis she had been receiving.  She was
started on low dose colchicine 0.6 daily, given concern for her
renal insufficiency, increasing to 0.6 [**Hospital1 **] as her renal function
improved.  This was dosed with Zofran as necessary for nausea.
Her uric acid level was 6.4. We started a low dose prednisone
burst that we recommended to the rehab hospital.
.
# Acute on chronic Renal Failure: Pt presented with Cr 1.9 which
decreased to 1.1 over course of hospitalization.  Her
antibiotics were renally dosed and adjusted for rapid changing
creatinine.
.
# Constipation: On Colace and senna at home, though has not been
taking recently. We suspect that this may be contributing to her
nausea.  She was managed on polyethylene glycol, Colace and
senna.
.
CHRONIC ISSUES:
.
# Afib: Pt has long history of afib with pacer in place.  We
continued her home medications of amiodarone and aspirin.
.
# CAD: Pt was continued on home regimen of simvastatin and
aspirin.  Her carvedilol has been held because blood pressure is
under good control.
.
# HTN:   Her Diovan and carvedilol has been held for low blood
pressure.
.
# Hypothyroidism: continued on home levothyroxine
.
TRANSITIONAL ISSUES:
#Code status: DNR, but OK to intubate per discussion with pt and
her daughter. Pt would like to defer all medical decisions to
her daughter, [**Name (NI) **], who is her HCP.
.
#Pt will need to complete 14 day course of antibiotics, last
dose to be given [**9-2**]
.
# Hospital course was prolonged by patient and family refusal to
have PICC placement.  It appears that her daughter, who is the
health care proxy, has a more limited understanding of English
than initially thought.  It is recommended that all future
conversations regarding health care be had with an interpreter.

.
# We have held her carvedilol and Diovan as her blood pressure
has been well controlled here without either.  She may require
re-initiation of these medications as an outpatient.

Medications on Admission:
ASA 81mg daily
Amiodarone 200mg daily
carvedilol 12.5mg [**Hospital1 **]
simva 20mg daily
diovan 80mg daily
meclizine 12.5mg [**Hospital1 **]
levothyroxine 50mcg daily
colace [**Hospital1 **]
senna [**Hospital1 **]
torsemide 40mg [**Hospital1 **]


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours): last dose 8/25.
6. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 g
Intravenous Q6H (every 6 hours): Last dose 8/25.
7. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000) mg
Intravenous Q 24H (Every 24 Hours): last dose 8/25.
8. torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. CONSIDER THESE MEDICATIONS
1. Metolazone 2.5 mg for weight gain (2lbs) or SOB
2. Predinsone 20-40mg for gout (5 day burst)
13. Outpatient Lab Work
Consider checking BMP to assess renal function on torsdemide
every 2-3 days. (Baseline 1.1-1.4)


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]

Discharge Diagnosis:
Primary:
pneumonia
pulmonary edema

Secondary:
Gout


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms [**Known lastname 4602**],

It was a pleasure taking care of you at [**Hospital1 827**].  You were admitted because you were having
trouble [**Hospital1 4605**].  You were found to have a pneumonia that we
are treating with IV antibiotics.  You went to the ICU for a few
days because you had too much fluid on your lungs. We gave you
medicine to help you get rid of the extra fluid. The diuresis
caused a painful left leg gout flare that we treated with
colchicine and one dose of prednisone. We place an IV line
called a PICC line to give you antibiotics until [**9-2**].

The following changes were made to your medications:
1. Please take vancomycin 1500 mg IV every 48 hours until [**9-2**]
2. Please take Piperacillin-Tazobactam 2.25 g IV every 6 hours
until [**9-2**]
3. Please take Ciprofloxacin 750 mg by mouth once a day
4. Please take colchicine 0.6mg by mouth daily until foot pain
resolves
5. please stop taking meclizine
6. Please stop taking carvedilol and diovan. You may discuss
restarting this with your PCP.
7. Please take metolazone 2.5mg by mouth as necessary for weight
gain (2lbs) or shortness of breath.
8. Consider a 5 day burst of prednisone (20 or 40 mg) for your
gout

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day, or 5 pounds in 3 days.

Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2173-9-24**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2173-8-26**]
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Unspecified septicemia,Sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aortic valve disorders,Acute gouty arthropathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Constipation, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Do not resuscitate status,History of fall,Thrombocytopenia, unspecified'}


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: AMS, shortness of breath

PRESENT ILLNESS: 88yo F PMhx CHF, HTN presenting w AMS in the setting of a fall.
1d prior to presentation, patient was getting out of bathtub
when she slipped; this was an observed fall by the patient's
VNA; no head strike, no LOC. Patient reports she initially felt
fine, and refused to go to the ED at that time. On day of
admisison, family reported that patient sounded confused over
the phone, acting "sleepy". Patient denied fevers, chills,
nausea/vomitting, cough, motor/sensory deficits; reported pain
over her L ribs from her fall. Patient's family brought her to
the ED for further evaluation.
.
On presentation to the ED, initial vital signs were 99.4 60
117/45 20 92%. Exam was remarkable for hematoma over L rib,
atraumatic head, mild abdominal tenderness; labs were
significant or WBC 5.9, Hct 34.7, platelets 122, ALT 44, AST 80,
BNP 3244, Cr 1.9, UA wnl, trop .03; CXR unremarkable, RUQ u/s
unremarkable, CT unremarkable; while in the ED patient spiked
fever to 101.3. Blood cx were sent and patient was given
vancomycin/zosyn and was admitted to medicine for further
management. At time of transfer, vital signs were 98.9 61 142/63
20 100%3L.
.
On arrival to the floor vital signs were 99.9 160/75 59 18
93%2L. On further questioning patient reported increased SOB and
constipation; denied headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, , BRBPR, melena, hematochezia, dysuria, hematuria.

MEDICAL HISTORY: 1. CAD - 3 Vessel, medically managed
2. Severe aortic stenosis. [**Location (un) 109**] of 0.8-1.0 cm2, AV gradient of
60-33 mmHg per recent echocardiogram performed in 03/[**2172**]. AVR
was considered but the pt refused surgery, and preferred to
continue on medical therapy.
3. paroxysmal atrial fibrillation, s/p pacemaker placement in
[**2158**] for tachy-brady syndrome, followed by generator change in
[**2169**]. Amiodarone was re-initiated in [**2171-7-10**] d/t increased
frequency of AF.
4. HTN
5. diastolic CHF
6. Hypothyroidism
7. Chronic lung nodules

MEDICATION ON ADMISSION: ASA 81mg daily
Amiodarone 200mg daily
carvedilol 12.5mg [**Hospital1 **]
simva 20mg daily
diovan 80mg daily
meclizine 12.5mg [**Hospital1 **]
levothyroxine 50mcg daily
colace [**Hospital1 **]
senna [**Hospital1 **]
torsemide 40mg [**Hospital1 **]

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: ADMISSION EXAM:
VS: 99.9 160/75 59 18 93%2L
GENERAL: NAD, comfortable
HEENT: NC/AT, PERRL, EOMI, MMM, OP clear
NECK: Supple, 6cm JVD, no LAD.
HEART: RRR, no MRG
LUNGS: Inspiratory crackles bilaterally, decreased breathsounds
at R base
ABDOMEN: Soft/NT/ND, suprapubic fullness, no rebound/guarding
EXTREMITIES: WWP, trace edema to ankle, 2+ DP/PT/radial pulses
NEURO: AOx3, CNs II-XII grossly intact, muscle strength 5/5 x4
extremities, gait not observed
.
DISCHARGE EXAM:
 Tm 99.6 Tc 99.5 131/41 59 20 95% 2L
General: Alert, no acute distress
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bilateral scattered crackles, worse at bases
CV: RRR, 3/6 systolic murmur radiates to carotids
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining transparent urine
Ext: warm, well perfused, 2+ pulses, no edema.  L foot/ankle
swollen with slight erythema, tender to touch over toes

FAMILY HISTORY: mult family members w +CAD

SOCIAL HISTORY: Patient lives alone in [**Location (un) 583**], with daughter [**Name (NI) **] (health care
proxy)
living nearby. Patient has help for cleaning and bathing,
does some cooking, daughter does shopping. Walks with walker.
Weekly VNA services. No h/o tobacco, ETOH. 

### Response:
{'Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Unspecified septicemia,Sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aortic valve disorders,Acute gouty arthropathy,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Constipation, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Do not resuscitate status,History of fall,Thrombocytopenia, unspecified'}
