CHIEF COMPLAINT: Back pain; Shortness of breath

PRESENT ILLNESS: [**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain.
Patient states she has chronic back pain which has gotten
significantly worse the last 3 days, reported refractory to
tylenol but pt says she doesn't take pain meds much at home (at
most one tylenol a day). Patient denies fever, chills, numbness,
weakness. She denies urinary retention or bowel incontinence.
She states she otherwise feels well. She's been using icy hot
patches to control the back pain. She denies abdominal pain or
diarrhea, but reports some constipation. She initially thought
her back pain was due to this, but it didn't resolve when she
had a large BM this AM. She denies dysuria or difficulty
urinating.

MEDICAL HISTORY: -CAD- s/p PCI to mid-[**Year (4 digits) **] and PCTA to OM1 ([**2165**])
-CHF- last [**Year (4 digits) 113**] [**2165-3-11**] prior to stenting, EF 40%
-Hypertension
-Diabetes mellitus II- diet controlled
-Dyslipidemia
-Chronic renal failure, stage IV
-GERD
-h/o breast cancer ([**2145**]), s/p lumpectomy
-s/p TAH for fibroids(age 39)
-s/p cataract surgery

MEDICATION ON ADMISSION: 1. amlodipine 7.5 mg PO Qd
2. carvedilol 12.5 mg PO BID
3. isosorbide mononitrate 60mg XR PO Qd
4. aspirin 162mg Qd
5. furosemide 80 mg PO BID
6. famotidine 20 mg PO Qd
7. nitroglycerin 0.3 mg Tablet, Sublingual PRN chest pain
8. lidocaine 5 %(700 mg/patch) 1 daily to site
9. docusate sodium 100 mg PO BID
10. lorazepam 0.5 mg PO HS (PRN anxiety)
11. Tramadol 50mg PO Q8h5s PRN pain - pt says she is not taking

ALLERGIES: Atorvastatin / Ibuprofen / Rosuvastatin

PHYSICAL EXAM: Admission exam:
VS - Temp 98.2F, BP 149/68, HR 66, R 18, O2-sat 99% on 2L NC, wt
106.7lbs
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, mid-systolic murmur
loudest at heart base
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
BACK - mildly TTP over lower thoracic/upper lumbar spine, also
with some paraspinal muscle tenderness to R of this area
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal neuro deficits

FAMILY HISTORY: Mother- died at age [**Age over 90 **]
Father- hypertension, died in 60s
Sister- age [**Age over 90 **], high blood pressure, CAD.

SOCIAL HISTORY: Lives alone in [**Location (un) 55**]. Walks with a cane. Has aids at
home to help. She has three children, two of which live close
by. HCP is daughter [**Name (NI) 553**].  [**Name2 (NI) 1139**]- <1ppd for 20 years, quit in
[**2144**].
Alcohol- denies, Illicits- denies
Acute on chronic systolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Acute respiratory failure,Chronic kidney disease, Stage IV (severe),Hyposmolality and/or hyponatremia,Candidiasis of mouth,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of breast,Personal history of tobacco use,Constipation, unspecified,Other acute pain,Backache, unspecified,Old myocardial infarction
Ac on chr syst hrt fail,Pneumonia, organism NOS,Toxic encephalopathy,Acute respiratry failure,Chr kidney dis stage IV,Hyposmolality,Thrush,Acute kidney failure NOS,Crnry athrscl natve vssl,Status-post ptca,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Hx of breast malignancy,History of tobacco use,Constipation NOS,Acute pain NEC,Backache NOS,Old myocardial infarct
Admission Date:  [**2167-4-22**]              Discharge Date:   [**2167-5-8**]


Service: MEDICINE

Allergies:
Atorvastatin / Ibuprofen / Rosuvastatin

Attending:[**First Name3 (LF) 2891**]
Chief Complaint:
Back pain; Shortness of breath

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain.
Patient states she has chronic back pain which has gotten
significantly worse the last 3 days, reported refractory to
tylenol but pt says she doesn't take pain meds much at home (at
most one tylenol a day). Patient denies fever, chills, numbness,
weakness. She denies urinary retention or bowel incontinence.
She states she otherwise feels well. She's been using icy hot
patches to control the back pain. She denies abdominal pain or
diarrhea, but reports some constipation. She initially thought
her back pain was due to this, but it didn't resolve when she
had a large BM this AM. She denies dysuria or difficulty
urinating.

In the ER, she also reported worsening shortness of breath that
began earlier today. Denied chest pain. Shortness of breath was
for approximately 2 hours earlier today. Now improved with nasal
cannula per ER report. On further questioning about this, she
says she is mildly short of breath at baseline going on walks or
rushing to bathroom at night. When pressed she says this has
actually worsened somewhat over last month and became acutely
worse today. However, this was not the reason she came to the
ER. She also reports a productive [**Year (4 digits) **] for roughly one month
with whitish sputum. She thought maybe she had bronchitis
because she gets bronchitis every year but hasn't had it yet
this year.

In the ED, initial VS: 99.6 74 162/88 26 99% 2L Nasal Cannula.
Trop was 0.02 (have been higher in past) and Cr 2.1. Due to SOB
D-dimer drawn and was elevated at 906. Lactate 1.2. CXR was
clear. CT torso showed -> question of early PNA with Right lower
lobe ground glass opacities so she was given CTX/Azithro after
blood cultures drawn. Given [**Year (4 digits) **]/Tylenol for back pain and or
ACS. Pt was admitted from the ER for V/Q scan due to concern for
PE in pt with elevated Cr. Back pain was considered
musculoskeletal in nature. VS on admission 98.7 ??????F (37.1 ??????C),
Pulse: 63, RR: 19, BP: 135/56, O2 sat 98% on 1L NC

Currently, pt feels much better than earlier today. She says the
main thing that has changed is that her back pain is better with
the meds she got in the ER (325mg [**Year (4 digits) **] and 325mg Tylenol).

REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, BRBPR, melena, hematochezia,
dysuria, hematuria.

Past Medical History:
-CAD- s/p PCI to mid-[**Year (4 digits) **] and PCTA to OM1 ([**2165**])
-CHF- last [**Year (4 digits) 113**] [**2165-3-11**] prior to stenting, EF 40%
-Hypertension
-Diabetes mellitus II- diet controlled
-Dyslipidemia
-Chronic renal failure, stage IV
-GERD
-h/o breast cancer ([**2145**]), s/p lumpectomy
-s/p TAH for fibroids(age 39)
-s/p cataract surgery

Social History:
Lives alone in [**Location (un) 55**]. Walks with a cane. Has aids at
home to help. She has three children, two of which live close
by. HCP is daughter [**Name (NI) 553**].  [**Name2 (NI) 1139**]- <1ppd for 20 years, quit in
[**2144**].
Alcohol- denies, Illicits- denies


Family History:
Mother- died at age [**Age over 90 **]
Father- hypertension, died in 60s
Sister- age [**Age over 90 **], high blood pressure, CAD.

Physical Exam:
Admission exam:
VS - Temp 98.2F, BP 149/68, HR 66, R 18, O2-sat 99% on 2L NC, wt
106.7lbs
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, mid-systolic murmur
loudest at heart base
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
BACK - mildly TTP over lower thoracic/upper lumbar spine, also
with some paraspinal muscle tenderness to R of this area
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal neuro deficits

Discharge Physical Exam:
VS:  98.3  133/63  68  18  96% RA  weight 46.3 kg
General:  NAD, tired but alert and oriented x3
HEENT:  EOMI, PERRL, anicteric, MMM, OP clear
CV:  RRR, nl S1 S2, [**3-16**] mid-systolic murmur
Resp:  CTAB, no wheezes or rhonchi, rales right base
Abd:  soft, non-tender, non-distended, no HSM
Ext:  warm, well-perfused, no edema, 2+ DP


Pertinent Results:
Admission labs:
[**2167-4-22**] 02:40PM BLOOD WBC-9.1# RBC-4.14* Hgb-13.5 Hct-36.8
MCV-89 MCH-32.7* MCHC-36.8* RDW-13.8 Plt Ct-188
[**2167-4-22**] 02:40PM BLOOD Neuts-80.6* Lymphs-12.6* Monos-4.9
Eos-1.2 Baso-0.7
[**2167-4-22**] 07:49PM BLOOD PT-12.2 PTT-30.2 INR(PT)-1.1
[**2167-4-22**] 02:40PM BLOOD Glucose-211* UreaN-52* Creat-2.1* Na-136
K-4.2 Cl-96 HCO3-26 AnGap-18
[**2167-4-22**] 02:40PM BLOOD ALT-19 AST-44* LD(LDH)-303* CK(CPK)-63
AlkPhos-108* TotBili-0.4
[**2167-4-22**] 02:40PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-[**Numeric Identifier 35383**]*
[**2167-4-22**] 02:40PM BLOOD Albumin-4.3
[**2167-4-22**] 05:50PM BLOOD D-Dimer-906*
[**2167-4-22**] 06:03PM BLOOD Lactate-1.2

Cardiac Enzymes:
[**2167-4-24**] 07:18AM BLOOD CK-MB-2 cTropnT-0.04*
[**2167-4-26**] 06:50AM BLOOD CK-MB-3 cTropnT-0.09*
[**2167-4-26**] 03:30PM BLOOD CK-MB-4 cTropnT-0.11*
[**2167-4-26**] 11:53PM BLOOD CK-MB-4 cTropnT-0.14*
[**2167-4-27**] 06:00AM BLOOD CK-MB-4 cTropnT-0.14*
[**2167-4-27**] 02:11PM BLOOD CK-MB-4 cTropnT-0.15*
[**2167-4-28**] 02:28AM BLOOD CK-MB-6 cTropnT-0.21*
[**2167-4-28**] 01:57PM BLOOD CK-MB-7 cTropnT-0.26*
[**2167-4-29**] 03:00AM BLOOD CK-MB-4 cTropnT-0.27*
[**2167-4-30**] 03:31AM BLOOD CK-MB-3 cTropnT-0.25*

Discharge Labs:
[**2167-5-8**] 06:55AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.5* Hct-33.6*
MCV-97 MCH-30.3 MCHC-31.3 RDW-16.4* Plt Ct-379
[**2167-5-4**] 07:10AM BLOOD Neuts-75.9* Lymphs-14.1* Monos-5.5
Eos-3.9 Baso-0.7
[**2167-5-8**] 06:55AM BLOOD Glucose-218* UreaN-116* Creat-3.1*
Na-126* K-3.9 Cl-81* HCO3-33* AnGap-16
[**2167-5-8**] 06:55AM BLOOD Calcium-9.4 Phos-5.1* Mg-3.7*

[**2167-4-22**]:
ECG:
Sinus rhythm. Borderline prolongation of the P-R interval. Left
atrial
abnormality. Left axis deviation. Left bundle-branch block.

[**2167-4-22**]:
CXR:
1. Confluent right lung base opacity, increased in conspicuity
since
[**2167-3-6**] exam, which may represent atelectasis, assymetric
edema or infection in the appropriate clinical setting.
2. Moderate cardiomegaly and perihilar vascular congestion,
unchanged.

[**2167-4-22**]:
CT torso w/o contrast:
1. Centrilobular ground-glass opacities, predominantly in basal
segments of
the right lower lobe, new since [**2164**] exam, suggestive of an
infectious or
inflammatory etiology. Punctate opacities in the left upper lobe
are also new since prior and may represent same underlying
infectious/inflammatory process.
2. Extensive calcified atherosclerotic disease of the aorta and
its branches without associated aneurysmal changes. Assessment
for dissection is limited, given lack of intravenous contrast.
High-grade stenosis of the
intra-abdominal aorta is likely given calcification pattern,
which is largely unchanged since [**2166-12-31**] exam.
3. Small hiatal hernia.
4. Marked atrophy of the right kidney, unchanged. Left renal
cyst.
5. Scattered sigmoid colon diverticula. No associated
inflammatory changes.

[**2167-4-25**]:
CXR:
1. Centrilobular ground-glass opacities, predominantly in basal
segments of
the right lower lobe, new since [**2164**] exam, suggestive of an
infectious or
inflammatory etiology. Punctate opacities in the left upper lobe
are also new since prior and may represent same underlying
infectious/inflammatory process.
2. Extensive calcified atherosclerotic disease of the aorta and
its branches without associated aneurysmal changes. Assessment
for dissection is limited, given lack of intravenous contrast.
High-grade stenosis of the
intra-abdominal aorta is likely given calcification pattern,
which is largely unchanged since [**2166-12-31**] exam.
3. Small hiatal hernia.
4. Marked atrophy of the right kidney, unchanged. Left renal
cyst.
5. Scattered sigmoid colon diverticula. No associated
inflammatory changes.

[**2167-4-26**]:
CXR:
As compared to the previous radiograph, the signs indicative of
pulmonary edema are seen in unchanged manner. The pre-existing
right pleural effusion has slightly increased in extent. The
pre-existing left pleural effusion is constant. No newly
occurred focal parenchymal opacities.

[**4-30**]:
CXR:
FINDINGS: In comparison with the study of [**4-29**], there is
continued
substantial enlargement of the cardiac silhouette with vascular
congestion and bilateral pleural effusions, more prominent on
the left with associated compressive atelectasis at the bases.
No evidence of acute focal pneumonia, though this could well be
hidden in the retrocardiac region on this single frontal view.

[**5-4**]:
CXR:
The heart is moderately enlarged. Bilateral pleural effusions
are enlarged since [**2167-5-1**]. There is slighlty increased
bibasilar atelectasis, severe on the left. There is no
pneumothorax.
IMPRESSION: Worsening bilateral pleural effusions and persistent
left lower lobe collapse.

MICROBIOLOGY:
Sputum culture [**4-24**]:
GRAM STAIN (Final [**2167-4-24**]):
      <10 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      RESPIRATORY CULTURE (Final [**2167-4-26**]):
      SPARSE GROWTH Commensal Respiratory Flora.
Urine culture [**4-22**], [**4-26**], [**4-27**], [**4-30**], [**5-1**] negative
Blood cultures 3/14, [**4-24**], [**4-26**] negative;  [**5-1**] NGTD


Brief Hospital Course:
[**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain and DOE with a [**Year (4 digits) **].  Imaging
consistent with PNA and CHF.  Hospital course complicated by
worsening CHF exacerbation and difficulty with diuresis [**3-12**] CKD
requiring transfer to the MICU for agressive diuresis.
.
# Acute on Chronic Systolic CHF: *****PATIENT'S DRY WEIGHT IS 46
KILOGRAMS***** Patient has known CAD with past PCIs and an
ischemic cardiomyopathy.  Most recent [**Month/Day (2) **] prior to this
admisison showed 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **] 40%, found to be worsened to 30%
with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) **] during this admission.  Her home dose of
Lasix is 80 mg [**Hospital1 **].  Initial exam was notable for elevated JVP
and bilateral crackles.  CXR consistent mostly with PNA with
mild vascular congestion.  During the first few days of
admission, patient did not respond to Lasix 80 mg IV or 120 mg
IV (output ~200-250 to each dose).  She initially had mild
improvement in symptoms but had increasing O2 requirement to
4LNC overnight on [**4-24**].  CXR showed worsening of bilateral
vascular congestion.  This may have been in the setting of
elevated SBP in the 160-170s.  BP control with nitropaste and
uptitration of amlodipine to 10mg (from 7.5) daily and imdur to
90mg (from 60mg) daily and carvedilol to 25mg (from 12.5mg) [**Hospital1 **].
 Patient not on [**Last Name (un) **]/ACE-i due to history of hyperkalemia on [**Last Name (un) **].
 More aggressive diuresis attempted with 10mg metolazone
followed by 100mg torsemide, with only mildly better results.
On [**4-27**] morning, the patient was noted to desat to 80% on
4.5LNC, 74% on RA and 90% on NRB and was sent to the MICU.  In
the MICU she was placed on a lasix gtt, in addition to
continuation of metolazone 10 mg [**Hospital1 **], averaging net negative one
liter per day.  This diuresis was augmented by decreasing her
carvedilol dose to 12.5 mg [**Hospital1 **] in an attempt to increase cardiac
output.  Her oxygen requirement decreased to 2-3L NC on transfer
out of the MICU and she was breathing much more comfortably.
There was discussion of possible UF session to remove fluid or
placement of a BIV pacer, but the patient declined both of these
procedures. *****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
.
On the floor, her diuresis was held due to worsening kidney
function.  Gentle diuresis with Lasix was restarted for several
days to help her reach her dry weight, which clinically appears
to be 46kg.  As her Cr increased again, her diuretics were again
held and she remained close to euvolemic thereafter.  She is not
being discharged on diuretics in order to allow further recovery
of her renal function.  It has been observed that she naturally
diureses when her HR is over 70, thus her carvedilol was reduced
in order to maintain her heart rate and improve her urine
output.  If her weight goes up while her HR is > 70, she may
require diuresis.  However, given her renal dysfunction, this
should be carefully considered in cooperation with her PCP and
Nephrologist to avoid future HD.
.
# Community Acquired Pneumonia: Patient presented with chronic
DOE, but much worse from baseline in the week prior to
presentation. In the ED, there was concern for PE and patient
underwent non-contrast CT (due to baseline CKD) which showed no
evidence of PE.  Leukocytosis (WBC 13.3 with PMN predominance),
CXR with hazy right lung base opacity and CT showing
perivascular infiltrates/ground glass appearance all suggested
pneumonia. She was treated for CAP (although she has been
hospitalized in [**2-/2167**]) and mild CHF exacerbation (see above).
Urine legionella antigen was negative. She was treated with
ceftriaxone (x8 days) and azithromycin (x5 day). Her dry,
congestive [**Year (4 digits) **] responded well to albuterol nebulizers,
expectorants and chest PT.  She continued to [**Year (4 digits) **] at discharge,
although without fever or leukocytosis to indicate continued
infection.  We anticipate this dry, occasionally productive
[**Year (4 digits) **] with wheezing will resolve over the next 1-2 weeks with
continued nebulizer treatments and [**Year (4 digits) **] suppressants.
.
# Chest pain/troponin elevation: Dyspnea was occasionally
accompanied by anterior chest pain, reproducible with palpation,
that resolved with improvement in respiratory status.  Unlikely
coronary origin.  However, patient did have a troponin bump to
0.21 (from 0.02 on admission) on [**4-29**] in the setting of acutely
worsening CHF, h/o CAD and CKD.  Troponins remained stable in
the low .2's.  CKMB negative.  Patient was continued on aspirin
81mg daily.
.
# Back Pain: Patient has chronic back pain, had worsened over 3
days prior to admission.  Patient has h/o spinal stenosis and
pain was similar in quality to baseline. Per patient, she only
takes at most one tablet of tylenol per day for fear of it
injuring her kidneys.  Pain well-controlled on standing tylenol
650mg q8h.
.
# Chronic Kidney Disease: Baseline creatinine 1.9-2.1. Arrived
at baseline and increased with diuresis, peaking at 3.3. This
was likely due to poor forward flow from CHF exacerbation and
diuresis.  Diuresis was paused with improvement in creatinine to
3.1.  The Nephrology team was consulted and felt that the
patient would likely recover over time, although possibly to a
lower baseline.   She was discharged with planned outpatient
Renal follow-up.  As diuresis worsens her renal function, it is
important to avoid diuresis if possible by controlling fluid
input and heart rate.
.
# HTN: Blood pressure mildly elevated, usually worsening in the
evening and overnight to SBP 160s and then stabilizing in SBP
130s-140s after morning home medications. In the setting of CHF
exacerbation and MR, BP control tightened.  Nitropaste used prn
and home meds uptitrated.  Patient not on ACE/[**Last Name (un) **] at baseline,
had history of hyperkalemia.
.
# Hyponatremia:  Likely due to CHF exacerbation and renal
injury.  Controlled with fluid restriction.
.
# Constipation: Patient reported chronic mild constipation at
home, was taking docusate. Responded to colace and senna.
Patient experienced mild nausea when constipated, resolved with
bowel regimen.
.
# Altered mental status:  Patient had an episode of
disorientation and agitation, likely hospital-acquired delirium,
perhaps exacerbated by uremia.  Famotidine and benzodiazepines
held.
.
# Groin rash:  Mild irritation secondary to having restricted
ambulation.  Miconazole topical started.
.
# Thrush:  Patient was found to have mild thrush, treated with
Nystatin, viscous lidocaine.
.
# Diabetes: Type II, controlled with diet at home.  The patient
had persistent hyperglycemia in the 200s.  We started her on NPH
prior to discharge for improved control, but this will likely
need continued titration.
.
# GERD: Continued home famotidine until episode of delirium,
then held.

Transitional Issues:
- If the patient's weight increases > 1 kg from her dry weight
of 46kg, please check her heart rate.  If HR < 70, please reduce
her carvedilol to improve her cardiac output and thus her
natural UOP.  If HR > 70, please contact the patient's PCP Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**] (covered by Dr [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) **] until [**5-16**]) to discuss
appropriate balance between diuresis and renal function in this
fragile patient.  Drs [**Last Name (STitle) 3029**] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] be reached at [**Company 191**],
[**Telephone/Fax (1) 2010**].
- Determination of home diuresis regimen to maintain weight and
respiratory status.
- Renal follow-up in [**3-13**] weeks to determine new baseline CKD,
adjust medications accordingly.
- The patient will likely have continued [**Last Name (LF) **], [**First Name3 (LF) **] require
support from bronchodilators and [**First Name3 (LF) **] suppressants, monitoring
for worsening symptoms that might indicate recurrent PNA.
Please discontinue [**First Name3 (LF) **] suppressants after 1 week.  Please
continue nebulizer treatments for periodic shortness of breath
and wheeze.
- The patient has episodic nausea, likely due to heartburn and
constipation.  Please maintain an aggressive bowel regimen
titrated to 2 soft stools daily.
- Please continue insulin sliding scale and NPH to ensure no
hyperglycemia.
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****
*****PATIENT'S DRY WEIGHT IS 46 KILOGRAMS*****

Medications on Admission:
1. amlodipine 7.5 mg PO Qd
2. carvedilol 12.5 mg PO BID
3. isosorbide mononitrate 60mg XR PO Qd
4. aspirin 162mg Qd
5. furosemide 80 mg PO BID
6. famotidine 20 mg PO Qd
7. nitroglycerin 0.3 mg Tablet, Sublingual PRN chest pain
8. lidocaine 5 %(700 mg/patch) 1 daily to site
9. docusate sodium 100 mg PO BID
10. lorazepam 0.5 mg PO HS (PRN anxiety)
11. Tramadol 50mg PO Q8h5s PRN pain - pt says she is not taking


Discharge Medications:
1. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed: take at onset of exertional chest pain;
may repeat every 5 minutes up to three times.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
7. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for [**First Name3 (LF) **], congestion.
Disp:*100 ML(s)* Refills:*0*
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours):
Hold for HR > 90. may hold in middle of night if pt sleeping
comfortably and non-hypoxic .
9. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1)  Mucous
membrane four times a day as needed for sore throat.
11. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day): Hold for SBP<90.
12. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours): may hold in middle of night if
pt sleeping comfortably and non-hypoxic .
13. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane Q4H (every 4 hours) as needed for mouth/throat pain:
swish and swallow .
14. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day): swish and swallow.
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
17. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day). Tablet(s)
18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: start [**5-8**]. Tablet(s)
19. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Six (6) units Subcutaneous twice a day.
20. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: 150-200 2 units
200-250 4 units
250-300 6 units
300-350 8 units
350-400 10 units.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]

Discharge Diagnosis:
Pneumonia
Acute on Chronic Systolic Heart Failure
Chronic Kidney Disease


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:
Ms. [**Known lastname 3659**],

It was a pleasure participating in your care at [**Hospital1 18**].  You were
admitted because you had difficulty breathing.  We found that
you had pneumonia and an exacerbation of your heart failure.  We
treated you with antibiotics.  We also treated you with
medications to help remove excess fluid from your lungs to
assist your breathing.

You also had back pain, which is an ongoing issue.  We treated
you with Tylenol around the clock and your back pain improved.
You can take up to 3 tablets of 650mg tylenol each day when you
go home for back pain.

You have continued to have occasional mild nausea and heartburn.
 This may be related to constipation, so we recommend using
laxatives to ensure [**2-9**] bowel movements/day.

Weigh yourself every morning. If your weight goes up by 3
pounds, please call Dr.[**Name (NI) 93519**] office.

We made the following changes to your medications:
STOP amlodipine, a blood pressure medication
STOP lidocaine patch and tramadol, used for back pain
STOP lorazepam and famotidine, which can worsen delirium
STOP furosemide, a diuretic

START Tylenol for pain
START hydralazine for blood pressure
START senna and Miralax as needed for constipation
START albuterol nebulizers, ipratropium nebulizers, guaifenesin
syrup, benzonatate, and cepacol for [**Name (NI) **]
START lidocaine and Nystatin swish and swallows for thrush
START miconazole cream for fungal rash
START insulin for high blood sugar
START [**Last Name (LF) **], [**First Name3 (LF) **] antibiotic, for 3 days for urinary tract
infection

REDUCE carvedilol and aspirin doses

Please follow-up with your physicians as listed below.

Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2167-5-19**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

We are working on a follow up appt in the with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in the 2-3 weeks. You will be called at the facility with the
appointment.   If you have not heard or have questions, please
call ([**Telephone/Fax (1) 10135**]
{'Acute on chronic systolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Acute respiratory failure,Chronic kidney disease, Stage IV (severe),Hyposmolality and/or hyponatremia,Candidiasis of mouth,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of breast,Personal history of tobacco use,Constipation, unspecified,Other acute pain,Backache, unspecified,Old myocardial infarction'}


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: Back pain; Shortness of breath

PRESENT ILLNESS: [**Age over 90 **]F w/ CAD (s/p PCI [**2165**]), CHF (EF 40%), HTN, DMII, CKD stage
IV, and h/o distant breast cancer who presented to the ED with
worsening lower back pain.
Patient states she has chronic back pain which has gotten
significantly worse the last 3 days, reported refractory to
tylenol but pt says she doesn't take pain meds much at home (at
most one tylenol a day). Patient denies fever, chills, numbness,
weakness. She denies urinary retention or bowel incontinence.
She states she otherwise feels well. She's been using icy hot
patches to control the back pain. She denies abdominal pain or
diarrhea, but reports some constipation. She initially thought
her back pain was due to this, but it didn't resolve when she
had a large BM this AM. She denies dysuria or difficulty
urinating.

MEDICAL HISTORY: -CAD- s/p PCI to mid-[**Year (4 digits) **] and PCTA to OM1 ([**2165**])
-CHF- last [**Year (4 digits) 113**] [**2165-3-11**] prior to stenting, EF 40%
-Hypertension
-Diabetes mellitus II- diet controlled
-Dyslipidemia
-Chronic renal failure, stage IV
-GERD
-h/o breast cancer ([**2145**]), s/p lumpectomy
-s/p TAH for fibroids(age 39)
-s/p cataract surgery

MEDICATION ON ADMISSION: 1. amlodipine 7.5 mg PO Qd
2. carvedilol 12.5 mg PO BID
3. isosorbide mononitrate 60mg XR PO Qd
4. aspirin 162mg Qd
5. furosemide 80 mg PO BID
6. famotidine 20 mg PO Qd
7. nitroglycerin 0.3 mg Tablet, Sublingual PRN chest pain
8. lidocaine 5 %(700 mg/patch) 1 daily to site
9. docusate sodium 100 mg PO BID
10. lorazepam 0.5 mg PO HS (PRN anxiety)
11. Tramadol 50mg PO Q8h5s PRN pain - pt says she is not taking

ALLERGIES: Atorvastatin / Ibuprofen / Rosuvastatin

PHYSICAL EXAM: Admission exam:
VS - Temp 98.2F, BP 149/68, HR 66, R 18, O2-sat 99% on 2L NC, wt
106.7lbs
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, mid-systolic murmur
loudest at heart base
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
BACK - mildly TTP over lower thoracic/upper lumbar spine, also
with some paraspinal muscle tenderness to R of this area
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal neuro deficits

FAMILY HISTORY: Mother- died at age [**Age over 90 **]
Father- hypertension, died in 60s
Sister- age [**Age over 90 **], high blood pressure, CAD.

SOCIAL HISTORY: Lives alone in [**Location (un) 55**]. Walks with a cane. Has aids at
home to help. She has three children, two of which live close
by. HCP is daughter [**Name (NI) 553**].  [**Name2 (NI) 1139**]- <1ppd for 20 years, quit in
[**2144**].
Alcohol- denies, Illicits- denies 

### Response:
{'Acute on chronic systolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Acute respiratory failure,Chronic kidney disease, Stage IV (severe),Hyposmolality and/or hyponatremia,Candidiasis of mouth,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of breast,Personal history of tobacco use,Constipation, unspecified,Other acute pain,Backache, unspecified,Old myocardial infarction'}
