CHIEF COMPLAINT: Chest pain, shortness of breath

PRESENT ILLNESS: PT is a 73 y.o woman with h.o diastolic HF, HTN, HL, PVD, DM,
ESRD on HD, PAF who presents after episode of CP/feeling
fatigued during her HD session today. Pt reports that she was
discharged from the hospital yesterday and was admitted for
chest discomfort+headache attributed to glaucoma. Pt reports
that her CP was midsternal/R.sided, dull ache, lasting for >1hr.
She reports an associated discomfort in the l.side of her neck.
She denies associated LH/Dizziness/diaphoresis,
nausea/vomiting/SOB, but does report feeling tired. States pain
resolved after being given "morphine" in the ED. In addtion, pt
reports no SOB/DOE, exertional CP at home. PT reports getting CP
2x/wk while lying flat in bed. Reports never exertional or while
standing/sitting up. Pt also states she experienced hypotension
during HD with BP 75.
.
Pt was taken to the ED where she was also found to be in
afib/RVR-rate to 114(not new), EKG showing ST depressions in
"v5-v6, I, II) that are reported as new but in comparison to
prior EKG are not. Pt found to be hypotensive to the 70's, given
500cc bolus and started on neosynephrine. BP up to 105 prior to
transfer. HR in 90's. L.IJ was placed for access. In addition,
pt was given 1 dose of Vanco/levo in ED for hypotension.
.
Currently, pt denies all ROS including headache/LH/Dizziness,
changes in vision, f/c, appetite/weight changes,
odynophagia/dysphagia, abdominal pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, (makes urine), joint pain/skin rash,
paresthesias/weakness.

MEDICAL HISTORY: - Hypertension
- Hypercholesterolemia
- Diastolic CHF with LVOT obstruction at rest
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- Paroxysmal atrial flutter, s/p failed ablation with subsequent

MEDICATION ON ADMISSION: B Complex-Vitamin C-Folic Acid 1 mg daily
Warfarin 2 mg Tablet daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops 1 drop QHS
Tiotropium Bromide 18 mcg Capsule 1 inh daily
Ranitidine HCl 150 mg Tablet daily
Lisinopril 30 mg 1 Tablet PO DAILY
4 units NPH [**Hospital1 **]
albuterol 1 puff [**Hospital1 **]
Aspirin 325 mg Tablet daily
Simvastatin 80 mg Tablet (1) Tablet PO once a day.
Diltiazem HCl 120 mg Capsule, SR 1 daily
Irbesartan 150 mg 1 daily
Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]
Sevelamer HCl 800 mg Tablet TID with meals.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T. 97.4, BP 96/54, HR 86, CVP 2, RR 14, sat 100% on RA
Gen: NAD, appears her stated age
HEENT: NC/AT, perrla, s/p cataract [**Doctor First Name **], EOMI, anicteric,
slightly dry MM, no oropharyngeal lesions/exudates
Neck: No JVP, no LAD. L.IJ c/d/i
Chest: B/L AE no w/c/r
Heart: S1S2 RRR, [**2-24**] diastolic murmur heard throughout
precordium, loudest in axilla crescendo/decrescendo in quality,
no r/g
Abd: + BS, soft, NT, ND, no bruits
Ext: No C/C/E, 2+radial/carotid/femoral pulses without bruits.
L.arm with fistula, C/D/I, non-tender, no erythema.
Neuro: AAOx3, CN2-12 intact, non-focal.

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Acute on chronic diastolic heart failure,Acute respiratory failure,Atrial flutter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Delirium due to conditions classified elsewhere,Secondary hyperparathyroidism (of renal origin),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Below knee amputation status,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery
Ac on chr diast hrt fail,Acute respiratry failure,Atrial flutter,Hyp kid NOS w cr kid V,End stage renal disease,Delirium d/t other cond,Sec hyperparathyrd-renal,DMII wo cmp nt st uncntr,Esophageal reflux,Status amput below knee,Periph vascular dis NOS,Hyperlipidemia NEC/NOS,Hypotension NOS,Crnry athrscl natve vssl
Admission Date:  [**2163-7-13**]              Discharge Date:   [**2163-7-21**]

Date of Birth:  [**2090-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest pain, shortness of breath

Major Surgical or Invasive Procedure:
Non-successful AFlutter albation
PICC d/ced in [**7-21**], right antecub

History of Present Illness:
PT is a 73 y.o woman with h.o diastolic HF, HTN, HL, PVD, DM,
ESRD on HD, PAF who presents after episode of CP/feeling
fatigued during her HD session today. Pt reports that she was
discharged from the hospital yesterday and was admitted for
chest discomfort+headache attributed to glaucoma. Pt reports
that her CP was midsternal/R.sided, dull ache, lasting for >1hr.
She reports an associated discomfort in the l.side of her neck.
She denies associated LH/Dizziness/diaphoresis,
nausea/vomiting/SOB, but does report feeling tired. States pain
resolved after being given "morphine" in the ED. In addtion, pt
reports no SOB/DOE, exertional CP at home. PT reports getting CP
2x/wk while lying flat in bed. Reports never exertional or while
standing/sitting up. Pt also states she experienced hypotension
during HD with BP 75.
.
Pt was taken to the ED where she was also found to be in
afib/RVR-rate to 114(not new), EKG showing ST depressions in
"v5-v6, I, II) that are reported as new but in comparison to
prior EKG are not. Pt found to be hypotensive to the 70's, given
500cc bolus and started on neosynephrine. BP up to 105 prior to
transfer. HR in 90's. L.IJ was placed for access. In addition,
pt was given 1 dose of Vanco/levo in ED for hypotension.
.
Currently, pt denies all ROS including headache/LH/Dizziness,
changes in vision, f/c, appetite/weight changes,
odynophagia/dysphagia, abdominal pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, (makes urine), joint pain/skin rash,
paresthesias/weakness.


Past Medical History:
- Hypertension
- Hypercholesterolemia
- Diastolic CHF with LVOT obstruction at rest
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- Paroxysmal atrial flutter, s/p failed ablation with subsequent

a. fib
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Chronic 2L NC at night
- Diabetes
- GERD/PUD
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
-L.eye "blind"


Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.


Family History:
Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.


Physical Exam:
Vitals: T. 97.4, BP 96/54, HR 86, CVP 2, RR 14, sat 100% on RA
Gen: NAD, appears her stated age
HEENT: NC/AT, perrla, s/p cataract [**Doctor First Name **], EOMI, anicteric,
slightly dry MM, no oropharyngeal lesions/exudates
Neck: No JVP, no LAD. L.IJ c/d/i
Chest: B/L AE no w/c/r
Heart: S1S2 RRR, [**2-24**] diastolic murmur heard throughout
precordium, loudest in axilla crescendo/decrescendo in quality,
no r/g
Abd: + BS, soft, NT, ND, no bruits
Ext: No C/C/E, 2+radial/carotid/femoral pulses without bruits.
L.arm with fistula, C/D/I, non-tender, no erythema.
Neuro: AAOx3, CN2-12 intact, non-focal.


Pertinent Results:
[**2163-7-12**] 03:25PM BLOOD WBC-6.4 RBC-4.58 Hgb-13.2 Hct-42.8 MCV-94
MCH-28.9 MCHC-30.9* RDW-18.9* Plt Ct-249
[**2163-7-13**] 04:46PM BLOOD PT-53.8* PTT-47.1* INR(PT)-6.2*
[**2163-7-12**] 03:25PM BLOOD Glucose-112* UreaN-56* Creat-8.0*# Na-137
K-4.0 Cl-91* HCO3-27 AnGap-23*
[**2163-7-12**] 03:25PM BLOOD Calcium-8.2* Phos-7.9*# Mg-2.4
[**2163-7-13**] 09:50AM BLOOD ALT-12 AST-22 CK(CPK)-62 AlkPhos-94
[**2163-7-13**] 09:50AM BLOOD Lipase-20

[**2163-7-13**] 09:50AM BLOOD CK(CPK)-62
[**2163-7-13**] 04:46PM BLOOD CK(CPK)-67
[**2163-7-14**] 01:10AM BLOOD CK(CPK)-222*
[**2163-7-14**] 02:31PM BLOOD CK(CPK)-162*
[**2163-7-13**] 09:50AM BLOOD cTropnT-0.06*
[**2163-7-13**] 04:46PM BLOOD CK-MB-NotDone cTropnT-0.42*
[**2163-7-14**] 01:10AM BLOOD CK-MB-33* MB Indx-14.9* cTropnT-1.21*
[**2163-7-14**] 02:31PM BLOOD CK-MB-20* MB Indx-12.3* cTropnT-1.32*

[**2163-7-13**] 09:50AM BLOOD Acetone-MODERATE

EKG [**2163-7-13**]: Atrial fibrillation. Left ventricular hypertrophy
with secondary repolarization abnormality. Cannot rule out
anteroseptal infarct - age undetermined. Inferior/lateral ST-T
changes may be due to hypertrophy and/or ischemia. Since
previous tracing of the same date, the heart rate is slower,
wide QRS eats not seen.

ECHOCARDIOGRAM [**2163-7-13**]: There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). A mid-cavitary gradient is identified (50-55 mmHg).
There is no definite dynamic LVOT gradient present. There is no
ventricular septal defect. The aortic valve leaflets (3) are
mildly thickened. The study is inadequate to exclude significant
aortic valve stenosis. No aortic regurgitation is seen. There is
severe mitral annular calcification. There is moderate
functional mitral stenosis (mean gradient 5 mmHg) due to mitral
annular calcification. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared to the prior study dated [**2163-3-24**], no definite change is
seen.
IMPRESSION: Severe LVH with signficant intracavitary gradient.
Tachycardia/AF. No regioanl LV systolic dysfunction.

CXR [**2163-7-13**]: No acute cardiopulmonary process.

CXR [**2163-7-14**]: Moderate-to-severe pulmonary edema is new. Mild
cardiomegaly unchanged. Pleural effusion, if any, is small.
There is no appreciable atelectasis. Left internal jugular line
tip projects over the junction of the brachiocephalic veins.


Brief Hospital Course:
Brief Hospital course: 73 year old female with hypertension,
hyperlipidemia, diastolic heart failure, hypertrophic
obstructive cardiomyopathy-like physiology secondary to left
ventricular hypertrophy, PVD, DM with ESRD on HD, paroxysmal
atrail fibrillation who presents after episode of chest pain and
hypotension during HD session on [**7-13**]. Patient transfered to the
CCU and requiring pressors to maintain her blood pressure.  She
was given fluids and was eventually weaned off of pressors.  Her
INR was elevated at 8 and she went in and out of normal sinus
rhythm, AFLutter and Afib.  She was dialysed on monday and
wednesday and was eventually brought down to a weight of 53kg
with a CVP of 5.  It was thought that this is her optimal weight
for her heart failure.  To avoid hypotension she was dialized
over the course of 4 hours instead of 3.   Pt. had a PICC line
placed while she was here which was removed before discharge.
She also underwent an EP study for ablation of atrial flutter
however no foci of flutter could be found in the right atrium
and the left atrium was not examined. No ablation occured, and
patient remained on Amiodarone.  She was given follow up
appointments with her cardiologist, primary care and she sees
renal for dialysis three days a week.


Problem [**Name (NI) **]:

# CHF: History of diastolic HF; pt with EF > 75%, severe LVH
without regional LV systolic dysfunction, no dynamic LVOT
obstruction at [**Name (NI) 5348**] but HOCM physiology when tachycardic. 4
kg taken off during HD likely resulted in hypotension, CP. No
longer required pressors after fluid bolus. Dry weight (without
prosthesis) is 53kg.
- Conservative HD for volume management; CVPs checked durring
dialysis, was 5 when dialized to weight ot 53kg.
- Pt restarted on home BP meds for BP control; should have beta
blocker pre-dialysis per Renal
.
# HTN: Pt with tenuous status as above, exacerbated by anxiety
- Restarted on home BP meds - CCB, ACE I, [**Last Name (un) **], beta blocker; all
but beta blocker held prior to dialysis this AM
- Was on Nitro drip, which was succesfully weaned
- Metoprolol IV prn for BP control
.
# Rhythm: Pt with paroxysmal afib with HR in 80s. Pt in and out
of A-Fib, A-Flutter and Normal Sinus Rhythm.  At risk of
worsening pump function if RVR present.
- Anticoagulation restarted.
- Continue beta blocker and CCB for HR control.
- Follow up with cardiologist as outpatient for lab testing
while on amiodarone.  Thyroid function tests and Liver function
tests twice a year; chest x-ray and pulmonary function tests
yearly.
- Given Amiodarone taper upon discharge.
.
# CAD/ischemia: Cardiac cath in [**1-28**] shows nonobstructive
disease in coronary arteries. Pt complained of chest pain on
admission which resolved with morphine. She had essentially
unchanged EKGs (ST segment depressions in I, II, V4-V6, AVL),
likely secondary to demand ischemia related to hypotensive
episode/afib with rapid ventricular responce. Currently remains
chest pain free, Her cardiac enzymes trended down.
- Continue apririn, statin, beta blocker, ACE I for primary
prevention
.
# Valves: Pt with mild functional MS [**First Name (Titles) **] [**Last Name (Titles) 113**].
.
# DM: history of DM type 2, on NPH [**Hospital1 **] at home; finger sticks
well controlled
- Continue with NPH and humalog sliding scale for blood sugar
coverage
- finger sticks four times a day while inpatient
- Continue with ACE I and [**Last Name (un) **]
.
# ESRD on HD: M/W/F, session today. Pt also with secondary
hyperparathyroidism
- Continue with dialysis schedule.
- continue renal meds, nephrocaps.
- Electrolytes were closely monitored.
.
# Pulmonary: Significant smoking history. Lungs hyperinflated on
CXR during last admission, on 2L nasla cannula at home.
Currently on nasal cannula, although she did require
nonrebreather when in flash pulmonary edema.
- Continue spiriva, albuterol
- Monitor O2 status
.
# Prophylaxis: Coumadin, spirometry, bowel regimen
.
# Access: Pt had PICC inserted and IJ inserted.  All lines
pulled for discharge/
.
# Code: Full discusssed with pt
.
# Communication: With pt


Medications on Admission:
B Complex-Vitamin C-Folic Acid 1 mg daily
Warfarin 2 mg Tablet daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops 1 drop QHS
Tiotropium Bromide 18 mcg Capsule 1 inh daily
Ranitidine HCl 150 mg Tablet daily
Lisinopril 30 mg 1 Tablet PO DAILY
4 units NPH [**Hospital1 **]
albuterol 1 puff [**Hospital1 **]
Aspirin 325 mg Tablet daily
Simvastatin 80 mg Tablet (1) Tablet PO once a day.
Diltiazem HCl 120 mg Capsule, SR 1 daily
Irbesartan 150 mg 1 daily
Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]
Sevelamer HCl 800 mg Tablet TID with meals.

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic twice a
day: each eye.
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
11. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): right eye.
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO BID (2 times a day).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Insulin NPH Human Recomb  Subcutaneous
15. Humalog Pen 100 unit/mL Insulin Pen Sig: as per sliding
scale  Subcutaneous four times a day.
16. Outpatient Lab Work
INR on Monday [**7-25**], please call results to PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 109103**] at [**Telephone/Fax (1) 250**] and [**Hospital6 733**] coumadin
clinic [**Telephone/Fax (1) 2173**].
17. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 7 days: continue through [**7-28**]. .
Disp:*28 Tablet(s)* Refills:*0*
18. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: continue through [**8-4**].
Disp:*14 Tablet(s)* Refills:*0*
19. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**8-5**].
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] [**Location (un) 269**]

Discharge Diagnosis:
Chest pain and hypotension during dialysis.
Hypertrophic Obstructive Cardiomyopathy
Acute on Chronic Diastolic Congestive Heart Failure.
Acute delirium


Discharge Condition:
Dry weight is 53 kg.
PICC line d/c'ed on [**2163-7-21**]
Delirium has cleared, MS [**First Name (Titles) **] [**Last Name (Titles) 5348**]


Discharge Instructions:
Your [**Last Name (Titles) 5348**] weight is 53 kg without your prostheses.  That
should be your goal weight for after dialysis.  Weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in one day or >6 lbs
over three days. Make sure your dialysis is over four hours not
three.
Please take your Lisinopril, irbesartan at night and take your
diltiazem after dialysis on Monday/Wednesday and Friday.

Please have your INR checked at dialysis and results called to
the coumadin clinic at [**Hospital6 733**]. [**Telephone/Fax (1) 2173**].

Adhere to 2 gm sodium diet, information was given to you at
discharge with detailed instructions on following a low sodium
diet.
Your amiodarone will be tapered over the next 3 weeks. you will
take 400mg twice a day until [**7-28**], then decrease to 400mg
once a day until [**8-4**], then decrease to 200mg daily and
continue indefinitely.
.
Your toprol was increased from 100mg twice a day to 150mg twice
a day.

Please stop smoking. Information was given to you on admission
regarding smoking cessation.

Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-10**] at 11:20am.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2163-8-29**]
11:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2163-12-7**]
1:40
Primary Care:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (resident) for [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 26455**],
MD Phone: [**Telephone/Fax (1) 250**]. Date/Time: Tuesday [**8-2**] at 2:20pm.
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Atrial flutter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Delirium due to conditions classified elsewhere,Secondary hyperparathyroidism (of renal origin),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Below knee amputation status,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery'}


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: Chest pain, shortness of breath

PRESENT ILLNESS: PT is a 73 y.o woman with h.o diastolic HF, HTN, HL, PVD, DM,
ESRD on HD, PAF who presents after episode of CP/feeling
fatigued during her HD session today. Pt reports that she was
discharged from the hospital yesterday and was admitted for
chest discomfort+headache attributed to glaucoma. Pt reports
that her CP was midsternal/R.sided, dull ache, lasting for >1hr.
She reports an associated discomfort in the l.side of her neck.
She denies associated LH/Dizziness/diaphoresis,
nausea/vomiting/SOB, but does report feeling tired. States pain
resolved after being given "morphine" in the ED. In addtion, pt
reports no SOB/DOE, exertional CP at home. PT reports getting CP
2x/wk while lying flat in bed. Reports never exertional or while
standing/sitting up. Pt also states she experienced hypotension
during HD with BP 75.
.
Pt was taken to the ED where she was also found to be in
afib/RVR-rate to 114(not new), EKG showing ST depressions in
"v5-v6, I, II) that are reported as new but in comparison to
prior EKG are not. Pt found to be hypotensive to the 70's, given
500cc bolus and started on neosynephrine. BP up to 105 prior to
transfer. HR in 90's. L.IJ was placed for access. In addition,
pt was given 1 dose of Vanco/levo in ED for hypotension.
.
Currently, pt denies all ROS including headache/LH/Dizziness,
changes in vision, f/c, appetite/weight changes,
odynophagia/dysphagia, abdominal pain/n/v/d/c/melena/brbpr,
dysuria/hematuria, (makes urine), joint pain/skin rash,
paresthesias/weakness.

MEDICAL HISTORY: - Hypertension
- Hypercholesterolemia
- Diastolic CHF with LVOT obstruction at rest
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- Paroxysmal atrial flutter, s/p failed ablation with subsequent

MEDICATION ON ADMISSION: B Complex-Vitamin C-Folic Acid 1 mg daily
Warfarin 2 mg Tablet daily
Brimonidine 0.15 % Drops DAILY
Latanoprost 0.005 % Drops 1 drop QHS
Tiotropium Bromide 18 mcg Capsule 1 inh daily
Ranitidine HCl 150 mg Tablet daily
Lisinopril 30 mg 1 Tablet PO DAILY
4 units NPH [**Hospital1 **]
albuterol 1 puff [**Hospital1 **]
Aspirin 325 mg Tablet daily
Simvastatin 80 mg Tablet (1) Tablet PO once a day.
Diltiazem HCl 120 mg Capsule, SR 1 daily
Irbesartan 150 mg 1 daily
Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]
Sevelamer HCl 800 mg Tablet TID with meals.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T. 97.4, BP 96/54, HR 86, CVP 2, RR 14, sat 100% on RA
Gen: NAD, appears her stated age
HEENT: NC/AT, perrla, s/p cataract [**Doctor First Name **], EOMI, anicteric,
slightly dry MM, no oropharyngeal lesions/exudates
Neck: No JVP, no LAD. L.IJ c/d/i
Chest: B/L AE no w/c/r
Heart: S1S2 RRR, [**2-24**] diastolic murmur heard throughout
precordium, loudest in axilla crescendo/decrescendo in quality,
no r/g
Abd: + BS, soft, NT, ND, no bruits
Ext: No C/C/E, 2+radial/carotid/femoral pulses without bruits.
L.arm with fistula, C/D/I, non-tender, no erythema.
Neuro: AAOx3, CN2-12 intact, non-focal.

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker. 

### Response:
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Atrial flutter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Delirium due to conditions classified elsewhere,Secondary hyperparathyroidism (of renal origin),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Below knee amputation status,Peripheral vascular disease, unspecified,Other and unspecified hyperlipidemia,Hypotension, unspecified,Coronary atherosclerosis of native coronary artery'}
