CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 66yo female transferred to the MICU after PEA arrest on the
floor.
**
66 yo female with severe COPD, Afib, hx of breast CA who
presented [**2142-1-24**] with respiratory distress most likely secondary
to COPD exacerbation in setting of respiratory infection. She
was treated in the MICU with BIPAP for brief period then
transferred to floor. Due to large loculated pleural effusion on
the left, which was unamenable to bedside thoracentesis, she was
scheduled for a Bronchoscopy/BAL and VATS with IP and thoracic
surgery. On the floor, she was treated with vanc/zosyn/levo.
*
Her hospital course was complicated by development of SVT
(afib/aflutter) and was started on diltiazem and quinidine as
per Electrophysiology team. The hospital course was also
complicated by ?volume overload and acid base imbalances. She
was taken to the OR on [**2142-1-30**] where she underwent decortication
due to difficulty decompressing the lung for VATS as well as
Bronchoscopy. The Bronchoscopy found significant thickened
mucous secretions which were suctioned out and during the
decortication, the patient was found to have a significant
empyema. 3 chest tubes were placed in the OR. The PACU course
was complicated by difficult extubation as well as marginal
respiratory status, CO2 retention (CO2 as high as 95 on ABG) and
acid base imbalance. She was successfully extubated on POD#1 and
transferred to floor on POD#2 on [**2142-2-1**].
*
After [**Hospital **] hospital course notable for: continued pain at
thoractoomy site treated with morhpine/dilaudid, complicated by
some waxing and [**Doctor Last Name 688**] mental status. Transient Afib/flutter
responsive to iv diltiazem. Chest tubes were dc'd on [**2-4**]. She
developed oliguric ATN, followed by renal [**2-5**] who felt due to
prerenal (due to transient inschemia from afib/flutter).
*
Then overnight on [**2-5**], noted to have increasing SOB and
complete white-out of left lung. She underwent bronch which
revealed a thick mucous plud in left mainstem bronchus. She
underwent repeat bronch on [**2-6**] at 14:40 with showed persistent
mucous plugging of L mainstem. Then at 17:20, RN checked gag
reflex which was present, and the patient was given dinner. RN
then noted the patient slumping over and hypoxia, and then code
was called at 17:25pm. Patient was found to be in PEA arrest.
Anesthesia intubated pt and suction showed food-stuffs from ET
tube. She was given epi x 2 and then atropine and bicarb. Spont
circulation resumed at 17:35. Pt was transferred to the MICU.
*
Repeat bronch on transfer to the MICU showed food particles in
the right and left stems, and a therapeutic aspiration was
performed. The ETT was advanced 2 cm to the carina.

MEDICAL HISTORY: 1.  COPD (FEV1 44%, on home O2)
2.  Afib
3.  h/o R breast ca s/p bx/lumpectomy (no chemo)
4.  GIB
5.  TTE ([**2-15**] with EF 50%)
6.  s/p appy

MEDICATION ON ADMISSION: 1.  Verapamil
2.  Digoxin
3.  Combivent
4.  Zocor

ALLERGIES: Latex / Reminyl / Ativan / Xanax

PHYSICAL EXAM: -VS: Tc: 96.9   BP: 108/66   HR: 113   RR: 22   SaO2: 94% on 3L
 wt: 230.1lb
-Gen: well nutritioned caucasian female lying in bed wearing NC
in NAD.  Pt is conversing in full sentences with no accessory
muscle use.
-HEENT: PERRL, EOMI, anicteric.  Non-tender, non-pruritic,
erythematous swelling around both eyes.  As per pt, no visual
changes.
-Neck: no retractions, JVD not appreciated
-CV: tachy, regular? s1, s2
-Chest: [**Month (only) **] bs, poor air movement, wheezing bilaterally [**12-17**] way
up back
-Abd: two vertical well healed surgical scars 20cm and 12cm in
mid abdomen, obese, soft, NT, ND, BS+
-Ext: UE: swelling L>R. no c/c/pitting edema (however le is
moderately swollen with non-pitting edema)
-Neuro: CN II-XII grossly intact

FAMILY HISTORY: 1.  Mother: died from burst hernia and subsequent peritonitis
2.  Father: died of throat CA; ex-smoker
3.  Sister: DM, CHF, recently passes away in [**May 2141**].
4.  No other family left for family.

SOCIAL HISTORY: The patient is a former nurses aide, waitress and now volunteers
at the Chaplain's office at B&W as well as at her local church.
She has never been married and does not have any children.  She
lives by herself in an appartment complex (intact ADL And IADL)
with a home maker who comes to visit once/week.  The patient
admits to having smoked 1ppd x 40+ years but quit 6 months ago.
She continues to report cigarette cravings.  She denies any
alcohol or illicit drug use.
Acute and chronic respiratory failure,Empyema without mention of fistula,Obstructive chronic bronchitis with (acute) exacerbation,Bacterial pneumonia, unspecified,Atrial fibrillation,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Mixed acid-base balance disorder,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Long-term (current) use of steroids,Constipation, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Swelling or mass of eye
Acute & chronc resp fail,Empyema w/o fistula,Obs chr bronc w(ac) exac,Bacterial pneumonia NOS,Atrial fibrillation,Ac diastolic hrt failure,Ac kidny fail, tubr necr,Mixed acid-base bal dis,Food/vomit pneumonitis,Foreign body bronchus,Long-term use steroids,Constipation NOS,DMII wo cmp nt st uncntr,Swelling or mass of eye
Admission Date:  [**2142-1-24**]              Discharge Date:   [**2142-2-21**]

Date of Birth:  [**2075-9-24**]             Sex:   F

Service: MEDICINE

Allergies:
Latex / Reminyl / Ativan / Xanax

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
Right subclavian triple lumen catheter
.
[**2142-2-9**]: 1. Bronchoscopy.2. Attempted video-assisted exploration
of the left pleural space with conversion to a left thoracotomy
and  decortication. Dr. [**Last Name (STitle) **].
.
Multiple Bronchoscopies: [**2142-2-5**]; [**2142-2-6**] x 2; [**2142-2-11**]; [**2142-2-12**];
[**2142-2-15**]
.
Endothracheal Intubation: [**2142-2-6**]
.
Arterial line: [**2142-2-7**]
.
Trach and PEG placement: [**2142-2-12**]
.
PICC line placement


History of Present Illness:
66yo female transferred to the MICU after PEA arrest on the
floor.
**
66 yo female with severe COPD, Afib, hx of breast CA who
presented [**2142-1-24**] with respiratory distress most likely secondary
to COPD exacerbation in setting of respiratory infection. She
was treated in the MICU with BIPAP for brief period then
transferred to floor. Due to large loculated pleural effusion on
the left, which was unamenable to bedside thoracentesis, she was
scheduled for a Bronchoscopy/BAL and VATS with IP and thoracic
surgery. On the floor, she was treated with vanc/zosyn/levo.
*
Her hospital course was complicated by development of SVT
(afib/aflutter) and was started on diltiazem and quinidine as
per Electrophysiology team. The hospital course was also
complicated by ?volume overload and acid base imbalances. She
was taken to the OR on [**2142-1-30**] where she underwent decortication
due to difficulty decompressing the lung for VATS as well as
Bronchoscopy. The Bronchoscopy found significant thickened
mucous secretions which were suctioned out and during the
decortication, the patient was found to have a significant
empyema. 3 chest tubes were placed in the OR. The PACU course
was complicated by difficult extubation as well as marginal
respiratory status, CO2 retention (CO2 as high as 95 on ABG) and
acid base imbalance. She was successfully extubated on POD#1 and
transferred to floor on POD#2 on [**2142-2-1**].
*
After [**Hospital **] hospital course notable for: continued pain at
thoractoomy site treated with morhpine/dilaudid, complicated by
some waxing and [**Doctor Last Name 688**] mental status. Transient Afib/flutter
responsive to iv diltiazem. Chest tubes were dc'd on [**2-4**]. She
developed oliguric ATN, followed by renal [**2-5**] who felt due to
prerenal (due to transient inschemia from afib/flutter).
*
Then overnight on [**2-5**], noted to have increasing SOB and
complete white-out of left lung. She underwent bronch which
revealed a thick mucous plud in left mainstem bronchus. She
underwent repeat bronch on [**2-6**] at 14:40 with showed persistent
mucous plugging of L mainstem. Then at 17:20, RN checked gag
reflex which was present, and the patient was given dinner. RN
then noted the patient slumping over and hypoxia, and then code
was called at 17:25pm. Patient was found to be in PEA arrest.
Anesthesia intubated pt and suction showed food-stuffs from ET
tube. She was given epi x 2 and then atropine and bicarb. Spont
circulation resumed at 17:35. Pt was transferred to the MICU.
*
Repeat bronch on transfer to the MICU showed food particles in
the right and left stems, and a therapeutic aspiration was
performed. The ETT was advanced 2 cm to the carina.


Past Medical History:
1.  COPD (FEV1 44%, on home O2)
2.  Afib
3.  h/o R breast ca s/p bx/lumpectomy (no chemo)
4.  GIB
5.  TTE ([**2-15**] with EF 50%)
6.  s/p appy


Social History:
The patient is a former nurses aide, waitress and now volunteers
at the Chaplain's office at B&W as well as at her local church.
She has never been married and does not have any children.  She
lives by herself in an appartment complex (intact ADL And IADL)
with a home maker who comes to visit once/week.  The patient
admits to having smoked 1ppd x 40+ years but quit 6 months ago.
She continues to report cigarette cravings.  She denies any
alcohol or illicit drug use.

Family History:
1.  Mother: died from burst hernia and subsequent peritonitis
2.  Father: died of throat CA; ex-smoker
3.  Sister: DM, CHF, recently passes away in [**May 2141**].
4.  No other family left for family.


Physical Exam:
-VS: Tc: 96.9   BP: 108/66   HR: 113   RR: 22   SaO2: 94% on 3L
 wt: 230.1lb
-Gen: well nutritioned caucasian female lying in bed wearing NC
in NAD.  Pt is conversing in full sentences with no accessory
muscle use.
-HEENT: PERRL, EOMI, anicteric.  Non-tender, non-pruritic,
erythematous swelling around both eyes.  As per pt, no visual
changes.
-Neck: no retractions, JVD not appreciated
-CV: tachy, regular? s1, s2
-Chest: [**Month (only) **] bs, poor air movement, wheezing bilaterally [**12-17**] way
up back
-Abd: two vertical well healed surgical scars 20cm and 12cm in
mid abdomen, obese, soft, NT, ND, BS+
-Ext: UE: swelling L>R. no c/c/pitting edema (however le is
moderately swollen with non-pitting edema)
-Neuro: CN II-XII grossly intact


Pertinent Results:
-EKG [**2142-1-24**]: SVT/Afutter in 150ss
-CXR [**2142-1-24**]: LL Opacification, obscuring of L CP angle
-CTA [**2142-1-25**]: Negative for PE.
-CXR on [**2142-2-18**]:

SUPINE PORTABLE CHEST: Comparison is made to a prior study dated
[**2142-2-16**]. Tracheostomy tube and left PICC catheter remain
in stable, satisfactory position. Heart is at the upper limits
of normal for size. Mediastinal contours are within normal
limits. As before, there is perihilar fullness and
indistinctness of pulmonary vasculature, in keeping with volume
overload. Allowing for differences in technique, the appearance
is unchanged. There is improved aeration of the left lower lobe,
with some patchy opacities persisting. There is blunting of the
costophrenic sulci bilaterally, suggesting small bilateral
pleural effusions. Numerous surgical clips are visualized in the
left upper abdomen.

IMPRESSION:

1) Stable volume overload.
2) Improved aeration of the left lower lobe

Labs on discharge:
wbc 8.5
hct 28.5
plt 388

na 142
k 4.1
cl 91
bicarb 43
bun 79
cr 3.2
glu 190
ca 8.5
mg 2.2
p 3.9
ABG 7.4/62/87


Brief Hospital Course:
1. Respiratory distress: Due to COPD flare in the setting of
bacterial pneumonia. Pt had a CTA while in MICU initially ruling
out PE which also found loculated left pleural effusions as well
as ascites and anasarca. Pt is s/p bronch and decortication with
chest tube placement for empyema. After her PEA arrest, she
remained in respiratory failure and ultimately underwent bedside
tracheostomy placement by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 57475**] on [**2142-2-12**].
Was unable to be weaned to PS due to low lung compliance,
presumably due to pneumonia, plueral effusion and total body
volume overload. She was placed on lasix drip and was diuresed.
Was able to tolerate PS for a short period of time on [**2142-2-19**]
15/15, and will require a very slow trach wean with trials of PS
each day.
.
A) PNA/Empyema: Pt with LLL infiltrate suggestive of PNA. Pt is
s/p bronch and decortication with chest tube placement for
empyema. Continued on vancomycin/zosyn for presumed
ventilator-associated pneumonia (course finished [**2142-2-19**]). She
received several bronchosopies during the course of her
hospitalization to clear secretions/mucous plugs.
.
C) COPD: Pt with significant COPD as per history (FEV1 44% on
home oxygen).  Continued on steroids, Albuterol and Atrovent
MDIs. Steroids were intially weaned on the floor to prednisone
30 qd, but were increased back up to 60 after PEA arrest. She is
now at 40 mg QD, and should get a very slow slow taper, given
her significant problems with bronchoconstriction.
.
D) CHF: Pt with non-pitting edema on LE, mild CHF on CXR and
generalized anasarca with ascites on CT scan suggestive of
volume overload.  Pt was actively diuresed on Sat with good
urine output and [**Month (only) **]. in LE edema. TTE was performed [**1-27**]
showing mod depressed cardiac function (EF 45-55%) and ?
diastolic dysfunction (LA and RA dilation, E wave decel 1m/sec
and E/A ratio of 1.43). Repeat TTE on [**2-7**] showed: EF 45-55%
(unchanged), resting regional wall  motion abnormalities
including inferior hypokinesis with mild to moderate hypokinesis
elsewhere.Right  ventricular systolic function is borderline
normal. (2+) mitral regurgitation. There is moderate pulmonary
artery systolic  hypertension (worse than prior). There is a
small pericardial effusion (unchanged)with some echo dense
material in the pericardial space consistent with some
organization. There are  no echocardiographic signs of
tamponade.  She was given lasix boluses with no effect, and on
[**2-14**] she was started on a lasix drip and diuresed well. She
became alkalotic however on [**2-19**] and lasix gtt was stopped and
patient was switched to Diamox. She will need careful repletion
of her lytes (keep potassium above 4.5) and if she becomes less
alkalotic, would recommend further diuresing her with more
lasix. She will be d/ced on diamox [**Hospital1 **] standing. She is still
>10 kgs up from her dry weight.
.
2. Atrial Fibrillation/Flutter: Pt with multiple episodes of
rapid Afib/flutter. She was initially started on diltiazem and
quinipril due to concern over lung toxicity associated wtih
amiodarone, but continued to have several episodes of rapid afib
both on the floor and again on her transfer to the MICU after
her PEA arrest.  Electrophysiology service was consulted and
quinidine was discontinued and the patient was started on an
amiodarone drip and was changed to po amiodarone and continued
on diltiazem. She continued to go in and out of paroxysmal Afib.
She was not anticoagulated given recent VATS and trach/PEG
placement, but this should be re-evaluated again after [**Month (only) 547**]
[**2141**] when is is 1 month post trach and PEG. Plan is to continue
amiodarone 200mg po qd. She needs a follow up appointment in [**Hospital **]
clinic. Please call Electrophysiology Clinic at ([**Telephone/Fax (1) 8793**]
for an appointment. She will need to be discontinued off of amio
given her underlying lung status in the near future.
.
3.  HTN: Pt previously off all hypertensives due to episodes of
hypotension in the MICU.  She was started back on verapamil but
was changed to diltiazem for better rate control in the setting
of rapid atrial fibrillation. Her blood pressure improved with
this treatment.
.
4.  ARF: Pt with steadily increasing BUN/Creatinie since
admission to [**Hospital1 18**]. Renal was consulted and diagnosed ATN due to
hypotension from the relative hypoperfusion during the episodes
of rapid Atrial fibrillation and PEA arrest.  Her creatinine
peak was 3.9 and began to improve on [**2-15**] after initiating lasix
drip.  Renal feels that her renal function will continue to
improve and she has no indication for dialysis at this time.
Please renally dose all medications and monitor electrolytes
daily.
.
5.  Hypercholesterolemia: continue zocor.
.
6. FEN. Volume status was treated as outlined above.  Her
electrolytes were repleted for goal K>4.0 and Mg>2.0. She was
started on tube feeds but did not tolerate due to high
residuals. A KUB performed [**2-15**] revealed constipation with good
rectal gas.  She was started on standing metoclopramide and
erythromycin for increased gastric motility and aggresive bowel
regiemen including enemas was continued.  Given her aspiration,
the team was reluctant to allow her to eat but patient insisted,
understanding the risks of doing this. She had no gag reflex but
was able to tolerate yogurt without aspirating over the last two
days of this admission. She was seen by speech and swallow on
[**2142-2-20**] who placed Passy-Muir valve and recommended NPO and a
video swallow to be performed. This should be done at rehab.
.
7. Anemia. Continued on epogen for anemia of chronic disease.
Had declines in her Hct during this admission thought related to
frequent phlebotomy, did not have ob+ stools. She did get 1
blood transfusion during this admission (pt. had significant
hematomas in the setting of her chest tubes. An SPEP/UPEP was
also sent in setting of renal failure and anemia. This is still
pending at discharge and should be followed up on to rule out
multiple myeloma.
.
8.  Prophylaxis: Heparin sub Q TID for DVT prophylaxis, colace
and senna for bowel regimen.
.
9. Constipation.  Patient with episodes of constipation and
increased residuals from Tube feeds. She was started on reglan,
lactulose, erythromycin, senna, colace with good effects.
.
10.  Access: RIJ central line intially placed then discontinued.
Patient had a PICC line placed on [**2-15**] by IR.
.
11.  Code status: Full code
.
12. Communication: Patient has so family but does have a friend
who is her health care proxy -- [**Name (NI) 1123**] [**Name (NI) **].

Medications on Admission:
1.  Verapamil
2.  Digoxin
3.  Combivent
4.  Zocor


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  PRN
(as needed).
5. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
7. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
8. Nicotine 7 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
9. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injectiojn Injection TID (3 times a day): until more mobile.
12. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): taper slowly over 1 month.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs
Inhalation Q2-4H (every 2 to 4 hours).
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q2-4H (every 2 to 4 hours).
15. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
17. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
18. insulin
1. 12 NPH [**Hospital1 **]
2. Regular insulin sliding scale:
150-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units
351-400 10 units
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO at bedtime
as needed for constipation: Hold for diarrhea.
20. Dulcolax 10 mg Suppository Sig: One (1) suppository Rectal
at bedtime: Hold if diarrhea.
21. Lactulose 10 g/15 mL Solution Sig: 30-60 mL PO three times a
day as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Nosocomial Pneumonia complicated by empyema
Congestive Heart Failure Exacerbation
Acute Renal Failure due to Acute Tubular Necrosis
Rapid Atrial Fibrillation
Constipation
Diabetes Mellitis Type II
Anemia of Chronic Disease
Chronic Obstructive Pulmonary Disease exacerbation
Pulseless Electrical Activity Arrest
Aspiration


Discharge Condition:
good on vent with settings of AC 550/10/15/35%had one trial for
about 2 hours of CPAP/PS 15/15

Discharge Instructions:
Please call PCP or return if have an increase in shortness of
breath, fevers or pain.

Followup Instructions:
PCP: [**Name10 (NameIs) 357**] follow up with your PCP within two weeks of
discharge from rehab.

Cardiology: Please follow up with Dr. [**Last Name (STitle) **] in one month for
evaluation of your atrial fibrillation/atrial flutter.  ([**Telephone/Fax (1) 8998**]
{'Acute and chronic respiratory failure,Empyema without mention of fistula,Obstructive chronic bronchitis with (acute) exacerbation,Bacterial pneumonia, unspecified,Atrial fibrillation,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Mixed acid-base balance disorder,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Long-term (current) use of steroids,Constipation, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Swelling or mass of eye'}


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: SOB

PRESENT ILLNESS: 66yo female transferred to the MICU after PEA arrest on the
floor.
**
66 yo female with severe COPD, Afib, hx of breast CA who
presented [**2142-1-24**] with respiratory distress most likely secondary
to COPD exacerbation in setting of respiratory infection. She
was treated in the MICU with BIPAP for brief period then
transferred to floor. Due to large loculated pleural effusion on
the left, which was unamenable to bedside thoracentesis, she was
scheduled for a Bronchoscopy/BAL and VATS with IP and thoracic
surgery. On the floor, she was treated with vanc/zosyn/levo.
*
Her hospital course was complicated by development of SVT
(afib/aflutter) and was started on diltiazem and quinidine as
per Electrophysiology team. The hospital course was also
complicated by ?volume overload and acid base imbalances. She
was taken to the OR on [**2142-1-30**] where she underwent decortication
due to difficulty decompressing the lung for VATS as well as
Bronchoscopy. The Bronchoscopy found significant thickened
mucous secretions which were suctioned out and during the
decortication, the patient was found to have a significant
empyema. 3 chest tubes were placed in the OR. The PACU course
was complicated by difficult extubation as well as marginal
respiratory status, CO2 retention (CO2 as high as 95 on ABG) and
acid base imbalance. She was successfully extubated on POD#1 and
transferred to floor on POD#2 on [**2142-2-1**].
*
After [**Hospital **] hospital course notable for: continued pain at
thoractoomy site treated with morhpine/dilaudid, complicated by
some waxing and [**Doctor Last Name 688**] mental status. Transient Afib/flutter
responsive to iv diltiazem. Chest tubes were dc'd on [**2-4**]. She
developed oliguric ATN, followed by renal [**2-5**] who felt due to
prerenal (due to transient inschemia from afib/flutter).
*
Then overnight on [**2-5**], noted to have increasing SOB and
complete white-out of left lung. She underwent bronch which
revealed a thick mucous plud in left mainstem bronchus. She
underwent repeat bronch on [**2-6**] at 14:40 with showed persistent
mucous plugging of L mainstem. Then at 17:20, RN checked gag
reflex which was present, and the patient was given dinner. RN
then noted the patient slumping over and hypoxia, and then code
was called at 17:25pm. Patient was found to be in PEA arrest.
Anesthesia intubated pt and suction showed food-stuffs from ET
tube. She was given epi x 2 and then atropine and bicarb. Spont
circulation resumed at 17:35. Pt was transferred to the MICU.
*
Repeat bronch on transfer to the MICU showed food particles in
the right and left stems, and a therapeutic aspiration was
performed. The ETT was advanced 2 cm to the carina.

MEDICAL HISTORY: 1.  COPD (FEV1 44%, on home O2)
2.  Afib
3.  h/o R breast ca s/p bx/lumpectomy (no chemo)
4.  GIB
5.  TTE ([**2-15**] with EF 50%)
6.  s/p appy

MEDICATION ON ADMISSION: 1.  Verapamil
2.  Digoxin
3.  Combivent
4.  Zocor

ALLERGIES: Latex / Reminyl / Ativan / Xanax

PHYSICAL EXAM: -VS: Tc: 96.9   BP: 108/66   HR: 113   RR: 22   SaO2: 94% on 3L
 wt: 230.1lb
-Gen: well nutritioned caucasian female lying in bed wearing NC
in NAD.  Pt is conversing in full sentences with no accessory
muscle use.
-HEENT: PERRL, EOMI, anicteric.  Non-tender, non-pruritic,
erythematous swelling around both eyes.  As per pt, no visual
changes.
-Neck: no retractions, JVD not appreciated
-CV: tachy, regular? s1, s2
-Chest: [**Month (only) **] bs, poor air movement, wheezing bilaterally [**12-17**] way
up back
-Abd: two vertical well healed surgical scars 20cm and 12cm in
mid abdomen, obese, soft, NT, ND, BS+
-Ext: UE: swelling L>R. no c/c/pitting edema (however le is
moderately swollen with non-pitting edema)
-Neuro: CN II-XII grossly intact

FAMILY HISTORY: 1.  Mother: died from burst hernia and subsequent peritonitis
2.  Father: died of throat CA; ex-smoker
3.  Sister: DM, CHF, recently passes away in [**May 2141**].
4.  No other family left for family.

SOCIAL HISTORY: The patient is a former nurses aide, waitress and now volunteers
at the Chaplain's office at B&W as well as at her local church.
She has never been married and does not have any children.  She
lives by herself in an appartment complex (intact ADL And IADL)
with a home maker who comes to visit once/week.  The patient
admits to having smoked 1ppd x 40+ years but quit 6 months ago.
She continues to report cigarette cravings.  She denies any
alcohol or illicit drug use. 

### Response:
{'Acute and chronic respiratory failure,Empyema without mention of fistula,Obstructive chronic bronchitis with (acute) exacerbation,Bacterial pneumonia, unspecified,Atrial fibrillation,Acute diastolic heart failure,Acute kidney failure with lesion of tubular necrosis,Mixed acid-base balance disorder,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Long-term (current) use of steroids,Constipation, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Swelling or mass of eye'}
