CHIEF COMPLAINT: rapid pulse

PRESENT ILLNESS: (Per report, patient intubated)
Ms. [**Known lastname 656**] is an 88 yo F who is very active and in her usual
state of health until the morning of presentation.  She has a
history of vertigo and felt unwell this am.  She additionally
may have been slightly fatigued.  Given this, she remained in
bed most of the day.  When her daughter, who is a retired nurse,
visited her in the evening she took her pulse and found it to be
80.  Given this this is a rapid pulse for the patient, she was
brought to the ED.
.
In triage, initial ED VS were 97.6, 102, 122/87, 20.  Found to
be profoundly hypoxic.  Though not recorded in ED records,
patient was profoundly hypoxic and immediately placed on a NRB
without much improvement.  She was then intubated and continued
to have poor oxygenation on 100% FIO2, 10 PEEP with 90% O2Sat.
CXR did not reveal a clear source.  EKG with 90 bpm, SR, slight
LAD, rsR' V2.  CT head negative for acute bleeding.  CTA with
bilateral diffuse pulmonary emboli.  ABG on 80% FIO2 pH 7.40,
pCO2 42, pO2 61, HCO3 27.  She then suddenly had improved
oxygenation with ability to decrease her FIO2 to 70 and decrease
her PEEP.  Given improvement, decision was made to heparinize
rather the thrombolyse.
.
Upon arrival to MICU, patient is intubate, sedated and unable to
provide further history.
.
Unable to obtain ROS.

MEDICAL HISTORY: 1.  Anxiety.
2.  Hypertension.
3.  Hyperlipidemia.
4.  Diverticulitis.
5.  Breast cysts.
6.  Osteoarthritis.
7.  Osteoporosis.
8.  Polycythemia [**Doctor First Name **].
9.  Vertigo.
10.  Skin cancer.
11.  Right Rotator cuff problems
.
PAST SURGICAL HISTORY:
1.  Status post breast cyst excisions x3.
2.  Status post hemorrhoidectomy.
3.  Status post surgical excision of basal cell carcinoma x2.
.
GYNECOLOGIC HISTORY:  Gravida 3, para 2, 2 vaginal deliveries, 1
spontaneous abortion.  Menarche in her teens.  Menopause at age
55.  Last Pap smear unknown.  Last mammogram in 2/[**2142**].

MEDICATION ON ADMISSION: Active Medication list as of [**2146-3-9**]:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once
a week
ALLOPURINOL - 100 mg Tablet - one Tablet(s) by mouth once daily
for 6 days out of the week.
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
DIAZEPAM - 2 mg Tablet - [**11-20**] or 1 Tablet(s)(s) by mouth at
bedtime as needed for insomnia
FELODIPINE - 5 mg Tablet Sustained Release 24 hr - 1 Tablet(s)
by mouth once a day for BP
HYDROXYUREA - 500 mg Capsule - one Capsule(s) by mouth once a
day for six days a week
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
1 patch to R shoulder maximum 12 hrs in a 24 hr. period
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for vertigo
METOPROLOL TARTRATE - 50 mg Tablet - [**11-20**] Tablet(s) by mouth
twice a day
PROPOXYPHENE N-ACETAMINOPHEN - 100 mg-650 mg Tablet - 1
Tablet(s) by mouth at bedtime as needed for severe pain
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg
Capsule- 1 Capsule(s) by mouth once a day
ASPIRIN -  (Prescribed by Other Provider) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth three times weekly

ALLERGIES: Mevacor / Demerol / Adhesive Tape / Darvocet-N 100

PHYSICAL EXAM: Vitals: T: 98.4 BP: 136/70   P: 87 R: 22 O2: 96/70% FIO2
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP distended, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, thin
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Mildly mottled along chest
**********
On discharge: ambulatory, breathing comfortably on room air.

FAMILY HISTORY: Positive for CAD in her mother, positive for
diabetes in her mother, positive for hypertension in her mother,
and positive for brain cancer in her father.

SOCIAL HISTORY: She grew up in [**Location (un) 3786**], [**State 350**].  She is
married, has a husband who has [**Name (NI) 2481**] disease.  She has two
grown children.  She is a retired secretary and billing clerk.
No tobacco use.  Very rare alcohol use.  No drug use.
Acute respiratory failure,Other pulmonary embolism and infarction,Cerebral artery occlusion, unspecified with cerebral infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diastolic heart failure, unspecified,Unspecified disorder of kidney and ureter,Orthostatic hypotension,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Polycythemia vera
Acute respiratry failure,Pulm embol/infarct NEC,Crbl art ocl NOS w infrc,Ac DVT/emb prox low ext,Diastolc hrt failure NOS,Renal & ureteral dis NOS,Orthostatic hypotension,Hypertension NOS,Hyperlipidemia NEC/NOS,Osteoarthros NOS-unspec,Osteoporosis NOS,Polycythemia vera
Admission Date:  [**2146-4-7**]              Discharge Date:   [**2146-4-14**]


Service: MEDICINE

Allergies:
Mevacor / Demerol / Adhesive Tape / Darvocet-N 100

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
rapid pulse

Major Surgical or Invasive Procedure:
Lysis of pulmonary emboli with TPA
Intubation
Extubation


History of Present Illness:
(Per report, patient intubated)
Ms. [**Known lastname 656**] is an 88 yo F who is very active and in her usual
state of health until the morning of presentation.  She has a
history of vertigo and felt unwell this am.  She additionally
may have been slightly fatigued.  Given this, she remained in
bed most of the day.  When her daughter, who is a retired nurse,
visited her in the evening she took her pulse and found it to be
80.  Given this this is a rapid pulse for the patient, she was
brought to the ED.
.
In triage, initial ED VS were 97.6, 102, 122/87, 20.  Found to
be profoundly hypoxic.  Though not recorded in ED records,
patient was profoundly hypoxic and immediately placed on a NRB
without much improvement.  She was then intubated and continued
to have poor oxygenation on 100% FIO2, 10 PEEP with 90% O2Sat.
CXR did not reveal a clear source.  EKG with 90 bpm, SR, slight
LAD, rsR' V2.  CT head negative for acute bleeding.  CTA with
bilateral diffuse pulmonary emboli.  ABG on 80% FIO2 pH 7.40,
pCO2 42, pO2 61, HCO3 27.  She then suddenly had improved
oxygenation with ability to decrease her FIO2 to 70 and decrease
her PEEP.  Given improvement, decision was made to heparinize
rather the thrombolyse.
.
Upon arrival to MICU, patient is intubate, sedated and unable to
provide further history.
.
Unable to obtain ROS.


Past Medical History:
1.  Anxiety.
2.  Hypertension.
3.  Hyperlipidemia.
4.  Diverticulitis.
5.  Breast cysts.
6.  Osteoarthritis.
7.  Osteoporosis.
8.  Polycythemia [**Doctor First Name **].
9.  Vertigo.
10.  Skin cancer.
11.  Right Rotator cuff problems
.
PAST SURGICAL HISTORY:
1.  Status post breast cyst excisions x3.
2.  Status post hemorrhoidectomy.
3.  Status post surgical excision of basal cell carcinoma x2.
.
GYNECOLOGIC HISTORY:  Gravida 3, para 2, 2 vaginal deliveries, 1
spontaneous abortion.  Menarche in her teens.  Menopause at age
55.  Last Pap smear unknown.  Last mammogram in 2/[**2142**].


Social History:
She grew up in [**Location (un) 3786**], [**State 350**].  She is
married, has a husband who has [**Name (NI) 2481**] disease.  She has two
grown children.  She is a retired secretary and billing clerk.
No tobacco use.  Very rare alcohol use.  No drug use.


Family History:
Positive for CAD in her mother, positive for
diabetes in her mother, positive for hypertension in her mother,
and positive for brain cancer in her father.


Physical Exam:
Vitals: T: 98.4 BP: 136/70   P: 87 R: 22 O2: 96/70% FIO2
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP distended, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, thin
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Mildly mottled along chest
**********
On discharge: ambulatory, breathing comfortably on room air.

Pertinent Results:
Admission labs:
[**2146-4-7**] 10:58PM   TYPE-ART RATES-14/ TIDAL VOL-450 O2-100
PO2-61* PCO2-42 PH-7.40 TOTAL CO2-27 BASE XS-0 AADO2-628 REQ
O2-100 INTUBATED-INTUBATED VENT-CONTROLLED
[**2146-4-7**] 10:58PM   LACTATE-1.4
[**2146-4-7**] 10:58PM   freeCa-1.12
[**2146-4-7**] 10:00PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2146-4-7**] 10:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2146-4-7**] 10:00PM URINE  RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2146-4-7**] 09:38PM   GLUCOSE-158* UREA N-18 CREAT-0.9 SODIUM-135
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-24 ANION GAP-17
[**2146-4-7**] 09:38PM   D-DIMER-3415*
[**2146-4-7**] 09:38PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2146-4-7**] 09:38PM   WBC-13.2* RBC-4.83 HGB-15.5 HCT-46.4 MCV-96
MCH-32.2* MCHC-33.5 RDW-16.5*
[**2146-4-7**] 09:38PM   NEUTS-89.0* LYMPHS-6.8* MONOS-3.3 EOS-0.5
BASOS-0.4
[**2146-4-7**] 09:38PM   PLT COUNT-399
[**2146-4-7**] 09:38PM   PT-12.5 PTT-27.3 INR(PT)-1.1

IMAGING: CTA, CT Pelvis, CT Abdomen:
1. extensive pulmonary emboli extending from the distal main
pulmonary
arteries into essentially every major branch to the subsegmental
level.
2. enhancing right renal mass measuring up to 2.3 cm, concerning
for
malignancy
3. splenomegaly
4. stable pancreatic ductal dilation up to 5mm, compared to
[**2140**].
.
CT Head
no acute intracranial process
.
TTE: The left atrium is elongated. No atrial septal defect is
seen by 2D or color Doppler. A right-to-left shunt across the
interatrial septum is seen at rest. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is markedly
dilated with severe global free wall hypokinesis. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. There is no mass/thrombus in the
right ventricle. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion.

IMPRESSION: Dilated and hypokinetic right ventricle. At least
moderate pulmonary hypertension. Small, underfilled left
ventricle with normal systolic function. Patent foramen
ovale/small ASD with right-to-left shunting
.
MRI HEAD:IMPRESSION: Small areas of acute infarct in the left
parietooccipital region.
Mild-to-moderate brain atrophy and small vessel disease. No
evidence of
chronic microhemorrhages.
.
Discharge labs:
[**2146-4-14**] 06:03AM BLOOD WBC-7.8 RBC-4.08* Hgb-12.6 Hct-38.8
MCV-95 MCH-30.9 MCHC-32.5 RDW-15.2 Plt Ct-474*
[**2146-4-14**] 06:03AM BLOOD PT-13.1 PTT-33.2 INR(PT)-1.1
[**2146-4-14**] 06:03AM BLOOD Glucose-98 UreaN-19 Creat-0.6 Na-141
K-4.3 Cl-107 HCO3-26 AnGap-12
[**2146-4-14**] 06:03AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.8
.
[**4-11**] repeat echo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. A patent foramen ovale is present
with premature appearance of contrast after saline injection at
rest. . There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are structurally normal. There is a trivial/physiologic
pericardial effusion.

Compared with the prior study (images reviewed) of [**2146-4-8**],
the right ventricular cavity size is smaller and free wall
motion is improved. Premature appearance of saline is still seen
in the left heart, but the amount of saline contrast is reduced.

.
[**4-13**] MRI abdomen:
1. Study limited by respiratory motion artifact. No evidence of
enhancement of the 2.3 cm right renal lesion of concern on CT
[**2146-4-7**], which is compatible with a hemorrhagic cyst.
2. Other bilateral simple renal cysts measuring up to 6.4 cm.
3. Stable segmental dilatation of the main pancreatic duct,
unchanged going back to [**2141-7-20**]. No evidence of
obstructing pancreatic mass.
4. Small bilateral pleural effusions.
5. Splenomegaly.
6. Moderate lumbar dextroscoliosis.
.
u/s [**4-8**]:
IMPRESSION: Partially occlusive thrombus of the left popliteal
vein.


Brief Hospital Course:
# B/L pulmonary embolisms: Presenting with profound hypoxemia
but minimal other symptoms.  Large A-a gradient on admission.
Seemingly up to date on cancer screening and without prolonged
mobility or other RFs for PE however does have PCV which could
increase her risk.  Underwent TTE which showed RV dilation and
PFO. LENIs showed DVt popliteal vein. because of hemodynamic
compromise underwent thrombolysis in the ICU without any
complications. Continued on hep gtt but converting to lovenox or
coumadin held in light of tepeated LENIs which showed
progression of clot and concern that she may need IVC filter.
With PFO unclear best route for anti-coagulation +/- IVC filter;
decdided to do anticoagulation first with filter as an option if
the coumadin failed. Repeat TTE on the floor showed improvement
in RV strain with less flow across PFO. As such, decided to
transition to lovenox and coumadin bridge, with plan for
extended coumadin course. Although patient with infarct findings
on CT/MRI brain, neurology consultation showed benefit > risk
for both lysis and anticoagulation.
Cause for PE unknown, consider colonoscopy given patient has
never had one, gyn w/u given increasing abdominal distention
(MRI abd without evidence for malignancy, but consider MRI
pelvis or u/s). Factor V Leiden pending on discharge (low
probability, given it's patient's first clot, at age 88).
.
# Renall mass - seen on CT scan, concerning for malignancy; MRI
demonstrated hemorrhagic cyst rather than lesion concerning for
renal cell carcinoma. Decided benefit > risk for anticoagulation
nonetheless.
.
# Hypertension - Hypotensive in ED during peri-intubation
period.  Improved with decreased propofol.  Also with evidence
of RV dilation on CT concerning for strain and decrease CO.
Initially held home meds but became more hypertensive after
extubation and low dose captopril and metoprolol restarted prior
to transfer to the floor with good control. On floor, continued
home medications and BP was well-controlled initially but then
patient was orthostatic and lightheaded, so decided to hydrate
her with IVF and hold diuretic temporarily.
.
#  Hyperlipidemia.  Stable. Continued low-cholesterol diet and
Lipitor.
.
# Polycythemia [**Doctor First Name **]: Followed by Dr. [**Last Name (STitle) **]. Held
hydroxyurea and allopurinol initially and then restarted [**4-10**].
.
# Vertigo: Severe per report on morning of admission. Currently
asymptomatic in ICU. On the floor, with some lightheadedness and
some movement of objects, but unremarkable non-focal neuro exam.
Non-focal neuro exam pointed away from bleed/TIA.
Perhaps d/t long-standing vertigo versus hypoxia versus
orthostatic hypotension d/t dehydration.
.
# Delirium: Confusion occurred x1 night in ICU and x1 night on
floor. With reorientation, and by morning time, it resolved.
Non-focal neuro exam pointed away from bleed/TIA.
.
# Shoulder pain: d/t rotator cuff injury, very significant,
continued pain meds, set-up outpatient PT and OT f/u.
.
# Social stress: patient is sole caregiver for husband with
alzheimer's. social work consulted, and services provided upon
discharge to help patient and family with stress.
.
CODE status: FULL (confirmed with daughter on ICU admission)

Medications on Admission:
Active Medication list as of [**2146-3-9**]:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once
a week
ALLOPURINOL - 100 mg Tablet - one Tablet(s) by mouth once daily
for 6 days out of the week.
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
DIAZEPAM - 2 mg Tablet - [**11-20**] or 1 Tablet(s)(s) by mouth at
bedtime as needed for insomnia
FELODIPINE - 5 mg Tablet Sustained Release 24 hr - 1 Tablet(s)
by mouth once a day for BP
HYDROXYUREA - 500 mg Capsule - one Capsule(s) by mouth once a
day for six days a week
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
1 patch to R shoulder maximum 12 hrs in a 24 hr. period
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for vertigo
METOPROLOL TARTRATE - 50 mg Tablet - [**11-20**] Tablet(s) by mouth
twice a day
PROPOXYPHENE N-ACETAMINOPHEN - 100 mg-650 mg Tablet - 1
Tablet(s) by mouth at bedtime as needed for severe pain
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg
Capsule- 1 Capsule(s) by mouth once a day
ASPIRIN -  (Prescribed by Other Provider) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth three times weekly


Discharge Medications:
1. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
([**Doctor First Name **],MO,TU,WE,TH,FR).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diazepam 2 mg Tablet Sig: Half to one Tablet PO HS (at
bedtime) as needed for insomnia.
5. Felodipine 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO 6X/WEEK
([**Doctor First Name **],MO,TU,WE,TH,FR).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off. To right shoulder.
8. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for vertigo.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO at bedtime as needed for severe pain.
11. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours): Please give at 7am and 7pm
daily. Continue this medication until your primary care
physician tells you that your coumadin level is therapeutic.
Disp:*14 injection* Refills:*0*
12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Daily at 4pm:
Daily at 4pm: The dose of this medication will be adjusted by
your primary care physician based on the INR (coumadin level).
Disp:*100 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Bilateral pulmonary emboli
Acute infarct in the left parietooccipital region
Deep venous thrombosis
Hypertension
Orthostatic hypotension
Hypoxemia
Respiratory failure
Renal mass


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:
You were admitted to the hospital with bilateral blood clots in
your lungs, believed to be from blood clots in your legs
originally. You were in the ICU, on a breathing machine, because
of the severity of the clots resulting in low oxygen levels.
After giving a medicine to break-up the clots, your breathing
stabilized and you were then able to have the breathing tube
safely removed. On the regular floor, your symptoms resolved,
and your breathing stabilized.
Your hospital course was complicated by confusion, and this also
resolved, this was likely due to the hospital setting.
A CT scan showed a concerning lesion on your kidney, an MRI was
performed that showed a hemorrhagic cyst (benign).
An MRI of the head showed small stroke lesions in your brain,
but you did not clinically have symptoms from these very small
lesions.
.
Please continue to take your regular home medications, and ADD
the following:
- START lovenox injections to prevent further blood clots until
coumadin level is therapeutic
- START coumadin to thin your blood and prevent further blood
clots
- Temporarily hold Triamterene-HCTZ (dyazide, a diuretic) until
you follow-up with Dr. [**Last Name (STitle) **]
- Temporarily hold Aspirin until you follow-up with Dr. [**Last Name (STitle) **]

Followup Instructions:
Please attend the following primary care appointment:
.
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: TUESDAY [**2146-4-19**] at 12:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**]
Specialty: Internal Medicine
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
You will need to have labs checked at this visit.
.
Please attend the following hematology appointment:
.
Department: HEMATOLOGY/BMT
When: THURSDAY [**2146-4-21**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2146-4-19**]
{'Acute respiratory failure,Other pulmonary embolism and infarction,Cerebral artery occlusion, unspecified with cerebral infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diastolic heart failure, unspecified,Unspecified disorder of kidney and ureter,Orthostatic hypotension,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Polycythemia vera'}


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: rapid pulse

PRESENT ILLNESS: (Per report, patient intubated)
Ms. [**Known lastname 656**] is an 88 yo F who is very active and in her usual
state of health until the morning of presentation.  She has a
history of vertigo and felt unwell this am.  She additionally
may have been slightly fatigued.  Given this, she remained in
bed most of the day.  When her daughter, who is a retired nurse,
visited her in the evening she took her pulse and found it to be
80.  Given this this is a rapid pulse for the patient, she was
brought to the ED.
.
In triage, initial ED VS were 97.6, 102, 122/87, 20.  Found to
be profoundly hypoxic.  Though not recorded in ED records,
patient was profoundly hypoxic and immediately placed on a NRB
without much improvement.  She was then intubated and continued
to have poor oxygenation on 100% FIO2, 10 PEEP with 90% O2Sat.
CXR did not reveal a clear source.  EKG with 90 bpm, SR, slight
LAD, rsR' V2.  CT head negative for acute bleeding.  CTA with
bilateral diffuse pulmonary emboli.  ABG on 80% FIO2 pH 7.40,
pCO2 42, pO2 61, HCO3 27.  She then suddenly had improved
oxygenation with ability to decrease her FIO2 to 70 and decrease
her PEEP.  Given improvement, decision was made to heparinize
rather the thrombolyse.
.
Upon arrival to MICU, patient is intubate, sedated and unable to
provide further history.
.
Unable to obtain ROS.

MEDICAL HISTORY: 1.  Anxiety.
2.  Hypertension.
3.  Hyperlipidemia.
4.  Diverticulitis.
5.  Breast cysts.
6.  Osteoarthritis.
7.  Osteoporosis.
8.  Polycythemia [**Doctor First Name **].
9.  Vertigo.
10.  Skin cancer.
11.  Right Rotator cuff problems
.
PAST SURGICAL HISTORY:
1.  Status post breast cyst excisions x3.
2.  Status post hemorrhoidectomy.
3.  Status post surgical excision of basal cell carcinoma x2.
.
GYNECOLOGIC HISTORY:  Gravida 3, para 2, 2 vaginal deliveries, 1
spontaneous abortion.  Menarche in her teens.  Menopause at age
55.  Last Pap smear unknown.  Last mammogram in 2/[**2142**].

MEDICATION ON ADMISSION: Active Medication list as of [**2146-3-9**]:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth once
a week
ALLOPURINOL - 100 mg Tablet - one Tablet(s) by mouth once daily
for 6 days out of the week.
ATORVASTATIN [LIPITOR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
DIAZEPAM - 2 mg Tablet - [**11-20**] or 1 Tablet(s)(s) by mouth at
bedtime as needed for insomnia
FELODIPINE - 5 mg Tablet Sustained Release 24 hr - 1 Tablet(s)
by mouth once a day for BP
HYDROXYUREA - 500 mg Capsule - one Capsule(s) by mouth once a
day for six days a week
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply
1 patch to R shoulder maximum 12 hrs in a 24 hr. period
MECLIZINE - 12.5 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for vertigo
METOPROLOL TARTRATE - 50 mg Tablet - [**11-20**] Tablet(s) by mouth
twice a day
PROPOXYPHENE N-ACETAMINOPHEN - 100 mg-650 mg Tablet - 1
Tablet(s) by mouth at bedtime as needed for severe pain
TRIAMTERENE-HYDROCHLOROTHIAZID [DYAZIDE] - 37.5 mg-25 mg
Capsule- 1 Capsule(s) by mouth once a day
ASPIRIN -  (Prescribed by Other Provider) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth three times weekly

ALLERGIES: Mevacor / Demerol / Adhesive Tape / Darvocet-N 100

PHYSICAL EXAM: Vitals: T: 98.4 BP: 136/70   P: 87 R: 22 O2: 96/70% FIO2
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP distended, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, thin
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Mildly mottled along chest
**********
On discharge: ambulatory, breathing comfortably on room air.

FAMILY HISTORY: Positive for CAD in her mother, positive for
diabetes in her mother, positive for hypertension in her mother,
and positive for brain cancer in her father.

SOCIAL HISTORY: She grew up in [**Location (un) 3786**], [**State 350**].  She is
married, has a husband who has [**Name (NI) 2481**] disease.  She has two
grown children.  She is a retired secretary and billing clerk.
No tobacco use.  Very rare alcohol use.  No drug use. 

### Response:
{'Acute respiratory failure,Other pulmonary embolism and infarction,Cerebral artery occlusion, unspecified with cerebral infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Diastolic heart failure, unspecified,Unspecified disorder of kidney and ureter,Orthostatic hypotension,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Osteoporosis, unspecified,Polycythemia vera'}
