CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: The patient is a 79yo M with PMH of PE on coumadin, sytolic HF
(EF 35%), AS, Prostate CA, ETOH use who presented to OSH with
SOB and increased swelling of right leg with known DVT. + Cough
and ? low grade temps. AT [**Location (un) 620**], VS: T99.6, 107, [**11/2156**], 20,
93% 4L. LENI noted extension of DVT and patient was given
lovenox 100mg x 1. Also noted to have elevated troponin 0.33 and
BNP 10,190. Given lasix 10mg IV x 1. Also 1" nitropaste. Patient
then transfered to [**Hospital1 18**] for further management.
.
In the ED, VS: T 99.6 HR 107 BP 111/87 RR 20 93% on 4L. Patient
underwent CTA that showed interval improvement in previously
noted PEs with no new thrombi. Patient was given dose of
ceftriaxone, azithro for concern of pneumonia.
.
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.

MEDICAL HISTORY: # Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

MEDICATION ON ADMISSION: ASA 325mg daily
Coumadin
Lasix 20 daily
Lisinopril 2.5 daily
Simvastatin 10mg daily
Pantoprazole 40 PO daily
Ipatropium
Albuterol

ALLERGIES: Bacitracin

PHYSICAL EXAM: VS: T 98.2 BP 115/48 HR 65 RR 24 97%5L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.
Subendocardial infarction, initial episode of care,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Mitral valve insufficiency and aortic valve stenosis,Orthostatic hypotension,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of prostate,Tobacco use disorder,Unspecified essential hypertension
Subendo infarct, initial,Acute respiratry failure,Obs chr bronc w(ac) exac,Ac on chr syst hrt fail,Mixed acid-base bal dis,Acute kidney failure NOS,Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Mitral insuf/aort stenos,Orthostatic hypotension,Alcoh dep NEC/NOS-contin,Hx-prostatic malignancy,Tobacco use disorder,Hypertension NOS
Name:  [**Known lastname 12733**],[**Known firstname 1340**]                Unit No:   [**Numeric Identifier 12734**]

Admission Date:  [**2181-8-23**]              Discharge Date:   [**2181-8-30**]

Date of Birth:  [**2102-3-8**]             Sex:   M

Service: MEDICINE

Allergies:
Bacitracin

Attending:[**Last Name (NamePattern1) 2539**]
Addendum:
Spoke with daughter of Mr [**Known lastname **], [**First Name5 (NamePattern1) 302**] [**Name (NI) 12735**] [**Telephone/Fax (1) 12736**]
who is the health care proxy and power of attorny about the
transfer to [**First Name9 (NamePattern2) 12737**] [**Location (un) 407**] today. She informed me that Mr
[**Known lastname 12738**] PCP is no longer Dr [**Last Name (STitle) 12739**] who was documented in the
chart. He is now seeing Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 12740**].  They
perfered to arrange an apointment with Dr. [**Last Name (STitle) **] on there own
schedule rather than myself arranging one for her. She also
imformed me that Mr. [**Known lastname **] had seen a cardiologist in [**Location (un) 407**]
prior to admission. She will discuss with the family whether
they will f/u in [**Location (un) 407**] or attend the standing apt I arranged
with Dr [**Last Name (STitle) 12741**].

Unfortunately Mr [**Known lastname **] had already left for [**Known lastname 12737**] with d/c
paperwork prior to this update. The family was glad to update
[**Known lastname 12737**] of the change of PCP.

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 176**] Of [**Location (un) 407**]

                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(1) 2541**]

Completed by:[**2181-8-30**]

Admission Date:  [**2181-8-23**]              Discharge Date:   [**2181-8-30**]

Date of Birth:  [**2102-3-8**]             Sex:   M

Service: MEDICINE

Allergies:
Bacitracin

Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 79yo M with PMH of PE on coumadin, sytolic HF
(EF 35%), AS, Prostate CA, ETOH use who presented to OSH with
SOB and increased swelling of right leg with known DVT. + Cough
and ? low grade temps. AT [**Location (un) 620**], VS: T99.6, 107, [**11/2156**], 20,
93% 4L. LENI noted extension of DVT and patient was given
lovenox 100mg x 1. Also noted to have elevated troponin 0.33 and
BNP 10,190. Given lasix 10mg IV x 1. Also 1" nitropaste. Patient
then transfered to [**Hospital1 18**] for further management.
.
In the ED, VS: T 99.6 HR 107 BP 111/87 RR 20 93% on 4L. Patient
underwent CTA that showed interval improvement in previously
noted PEs with no new thrombi. Patient was given dose of
ceftriaxone, azithro for concern of pneumonia.
.
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.

.
Of note, patient triggered on the floor at time of evaluation.
He developed acute shortness of breath, tachycardia with sats of
85% on 5L (though patient was mouthbreathing). Lung exam was
notable for poor air movement and diffuse wheezes. He improved
with ipratropium, levalbuterol, 10 IV lasix.


Past Medical History:
# Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

  of RML, RLL, LLL distal vessels
# Extensive mural thrombus of aortic arch and descending
  abdominal aorta
# RLE DVT
# Prostate CA s/p radiation
# Hypercholesterolemia
# COPD
# Hx of ETOH abuse

Social History:
Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son.


Family History:
FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.


Physical Exam:
VS: T 98.2 BP 115/48 HR 65 RR 24 97%5L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 8 cm at 60 degrees
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were labored with poor air movement, diffuse wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: R leg 3+ pitting edema to knee;
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
[**2181-8-23**] 07:05PM   cTropnT-0.55*
[**2181-8-23**] 07:05PM   CK(CPK)-224*

[**2181-8-23**] 07:05PM
WBC-8.7 RBC-3.75* HGB-11.5* HCT-35.1* MCV-94 MCH-30.7 MCHC-32.8
RDW-13.7
NEUTS-70.9* LYMPHS-17.1* MONOS-5.8 EOS-5.9* BASOS-0.3
PLT COUNT-272
PT-19.3* PTT-39.2* INR(PT)-1.8*
GLUCOSE-113* UREA N-16 CREAT-1.1 SODIUM-135 POTASSIUM-4.6
CHLORIDE-95* TOTAL CO2-30 ANION GAP-15

[**2181-8-23**] 07:15PM URINE
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG
RBC-0-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2
URINE  HYALINE-0-2

CTA [**2181-8-23**]:
1. No new pulmonary emboli. Small resolving pulmonary emboli in
the lower lobes bilaterally, right middle lobe, and left upper
lobe, smaller than the prior CTA of the chest [**2181-7-12**].
2. Increasing mediastinal and hilar lymphadenopathy of unclear
etiology. Attention should be paid on followup exams to ensure
resolution.
3. Two small pulmonary nodules measuring 3 and 6 mm in the right
lung, the larger of which is likely related to atelectasis and
unchanged from recent prior exam. Followup CT in six months is
recommended to ensure stability.

[**2181-8-24**] 03:30AM BLOOD CK-MB-12* MB Indx-7.0* cTropnT-0.66*
[**2181-8-25**] 05:41AM BLOOD CK-MB-NotDone cTropnT-0.26*

[**8-26**] LENI:
1. Right lower extremity nonocclusive DVT involving the right
external iliac,
common femoral, superficial femoral, and popliteal veins.
Questionable
extension into the IVC. This can be better evaluated at time of
dedicated
venogram during IVC filter placement.

2. No left-sided deep venous thrombosis.


Brief Hospital Course:
A+P [**8-29**]: 79y/o with PE, [**Month/Year (2) 7792**], COPD exacerbation, transfered
back to floor from CCU after breathing improved with diuresis,
steroid, and NIPPV.
.
#. [**Month/Year (2) 7792**]: Pt ruled in with [**Month/Year (2) 7792**] with troponin peak of 0.66.
Pt denies having Chest pain at all, however he is not a could
historian and is unclear of his presenting symptoms. Talked with
family, was SOB, and consfused upon admission. There are no EKG
changes, although it is hard to evaluate it in setting of LBBB.
 Medically manage [**Name (NI) 7792**], pt did not get cath on admission
because to unstable on presentation. No cath at this time since
the ischemic event is complete.  Unable to do stress test at
this time, can not exercise (fall risk), reluctant to do
dobutamine in setting of ACS, Persantine contraindicated in COPD
exacerbation. Will need chemical stress when COPD treatment
complete likely after pt d/c to rehab.
Was on heparin gtt, stoped [**8-29**] after INR was 2.0 x 3. Also on
ASA 81mg daily, simvastatin 80mg, Metoprolol 12.5mg [**Hospital1 **],
lisinopril 5mg, Plavix 75 daily, will continue for 9 months in
setting of [**Hospital1 7792**]
.
#. Resp failure: Patient triggered for desaturation which caused
transer to CCU. Multifactorial, including systolic CHF (EF
30-35%), PE, COPD exacerbation.  Pt significantly improved with
nebs, steroids, levofloxacin, and diuresis.  Pt denies any meds
as outpt, however family confirms on ipatropium. CHF management,
as below.
For COPD exacerbation, finished steroid taper 8/21(2nd day
20mg), nebs, levofloxacin [**6-16**] day course. Pt aslso has PE,
improving as per CTA this admission, s/p IVC filter this
admission. Pt responding inappropriately on questioning [**8-29**].
ABG 7.48/48/62/37, lactate 2.4. Metabolic alk with compensatory
resp acidosis. Bordreline O2 on RA. F/u with VBG 7.39/56/41/35,
lactate 2.1. Lactate improving with hydration. Started on Oxygen
to improve PO2. Pt clinically improved since out of CCU,
breathing unlabored, lungs with decreased crackles
.
# PUMP/ acute on chronic systolic CHF: [**7-16**] echo moderate
regional left ventricular systolic dysfunction with sveere
hypokinesis of the basal to mid septum and anterior wall, EF
30-35%.  severe aortic valve stenosis (area 0.8-1.0cm2). Mild to
moderate ([**1-10**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. BNP over 10,000 at admission. Depressed
EF likely [**2-10**] CAD given focal abnormailites. Hessitant to
aggressively overdiurese given severe AS. Records state on 20mg
PO lasix at home. Had incrased lasix to 60 PO daily with one
additional 10IV lasix dose in setting of increased crackles.
This caused a Cr increase to 1.7 and pt was orthostatic with PT
on [**8-28**]. Lasix stoped for 2 days now, had bolus IVF, with
improved BP and Cr and crackles on lung exam has also
diminished. [**Month (only) 116**] need to restart maintance dose of 20 PO lasix in
future. Continue lisinopril 5mg, BB.
.
#HTN - On BB, ACE, prn lasix. Pt was orthostatic [**8-28**] with SBP
to 80, improved BP with boluses
.
#PE: PE discovered on previous admission in [**Month (only) 205**]. Resolving
according to CTA on this admission. Recent for DVT and PE
unclear. Distant h/o Prostate CA. The pt will need
hypercoagulable / CA workup as outpt. There was concern that the
PE lead to the [**Month (only) 7792**] and SOB/COPD flare. Repeat LENIs showed
extension of R DVT, possibly to IVC. Therefore pt had IVC filter
placed [**8-27**]. Pt was on heparin gtt until [**8-29**], as Warfarin
became theraputic. INR now 2.0 on 4 straight measurements. On
Warfarin 5mg daily plus 2.5mg [**8-29**]. Continue to monitor INR
.
# Metabolic alkalosis: ABG gotten [**8-29**] because of high HCO3 and
inapropriate question answering [**8-29**]. ABG 7.48/48/62, lactate
2.4. Met alk with compensatory resp acidosis, likely contraction
alk [**2-10**] diuresis. No GI losses noted. Repeated VBG after small
bolus, was 7.39/56/41/35, lactate 2.1, improving with hydration.
Continue to hold lasix and hydration if needs. KCL as needed.
HCO3 downtrending from 37 to 32 with this regimen. Etiology of
lactate elevation unclear, likely [**2-10**] recent MI or DVT/PE. No
evidence of infection.
.
#Eosinophilia - present for 2 months, now downtrending since
starting steroids. Dx includes Neoplasm (as above, needs
screening), undiagnosed asthma?, adrenal insufficiency (no e/o
hypotension or hypoglycemia, but has evidence of adrenal disease
on ct scan with normocytic anemia), connective tissue disease,
sacrdoidosis, parasites (do not know travel history). CTA did
show Increasing mediastinal and hilar lymphadenopathy of unclear
etiology which needs 6 month f/u. [**Month (only) 116**] work up for connective
tissue disorders as an outpt.

#Etoh abuse: Pt states drinkes 5-6 beers and 2 shots of vodka a
day, however family states has not had etoh since [**Month (only) 205**]
admission. Was on CIWA with valium, but not requiring doses.
Continue folic acid, thiamine. LFTs normal except elevated LDH
.
#change in MS: Pt is poor historian, unclear of what events
occured prior to or while in hospital, although he is oriented
x3. Family claims is at baseline. Ddx includes steroid or unit
induceed delirium, or Wernickes considering significant Etoh
history. Pt has waxing and [**Doctor Last Name 688**] orientation. Pt angry [**8-29**]
about not going home. family is concern he will try to leave
hospital. Told them we would get psych to determine decision
making capacity if necessary
.
# ARF: Cr trending down from 1.7 to 1.4 (.9 to 1.0 baseline).
Felt to be prerenal since downtrending with decreased diuresis
and hydration.
.
# GERD - PPI
.
#FEN: cardiac diet, repleat lytes prn
.
#Prophylaxis: Theraputic on coumadin, PPI, ISS while on steroids
(now may stop since done steroids)
.
#Code: DNR/DNI, confirmed with pt and family
.
#Dispo: plan for Rehab. PT wants agreeable with rehab on [**8-30**],
.
# Comm: Health care proxy #1 [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], #[**6-11**] [**Last Name (NamePattern1) 79102**].

They are also co-durable power of attorny. Will bring it
paperwork to have on chart.


Medications on Admission:
ASA 325mg daily
Coumadin
Lasix 20 daily
Lisinopril 2.5 daily
Simvastatin 10mg daily
Pantoprazole 40 PO daily
Ipatropium
Albuterol


Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
2. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Continue through [**8-31**].
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
Non ST elevation MI ([**Location (un) 7792**])
systolic congestive heart failure
acute renal failure
aortic stenosis - moderate to severe
mulitiple Pulmonary Embolism - R-upper/R-middle lobe artery, ext
mural thrombus aortic arch and descending abdominal aorta
RLE Deep Vein Thrombosis
Prostate CA s/p radiation
Hypercholesterolemia
COPD - unknown pfts, on albuterol med list at-home
Hx ETOH abuse
GERD


Discharge Condition:
stable: [**Location (un) 7792**] medically managed, needs stress test once COPD
exacerbation controled. PE resolving, s/p IVC filter. CHF
controled but needs further management of lasix dose. Waxing and
[**Doctor Last Name 688**] MS.


Discharge Instructions:
You were admitted to the hospital because you were short of
breath and were confused at home.  You were found to have a
heart attack ([**Doctor Last Name 7792**]) and be in heart failure (CHF) which
contributed to your shortness of breath. We are treating your
heart attack and heart failure with medicines. However your
fluid level continues to need adjustment and your lasix dose
with continue to be changed at the rehab facility.  You will
need further testing (a stress test) of your heart after you are
finished being treated for your COPD exacerbation. You should
discuss this when you go for your cardiology appointment.

You also had an exacerbation of your COPD (breathing problem)
and are being treated with steroids, an antibiotic
(Levofloxacin), and breathing treatments.

You were found to have a blood clot in your right leg (DVT) as
well as your lungs (pulmonary embolus) on your previous
admission to the hospital. The imaging of your lungs during this
admission (CTA) showed that the clot in your lung is resolving.
However imaging of your leg showed that the clot is getting
bigger. Therefore you got a IVC filter placed in your vein to
prevent future clots in your lungs. You are also on blood
thinners to treat the clot

The CTA (chest imaging) also showed enlarged lymph nodes
"increasing mediastinal and hilar lymphadenopathy" of unclear
etiology which needs follow up imaging in 6 months. You should
discuss this with your doctor.

In is important that you continue your efforts to stop drinking
when you return home. You are at increased risk for seriously
bleeding becuase of blood thinner if you fall.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3
lbs.
Adhere to 2 gm sodium diet
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.

If you became acutely short of breath or develop chest pain you
should return to the Emergency room.

Followup Instructions:
PCP: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) **], MA ([**Telephone/Fax (1) 79103**]). You need to
call for a appointment within the next two weeks.  You should
discuss the need for further imaging of your chest in six months
to follow up 'increasing mediastinal and hilar lymphadenopathy'
of unclear etiology. Also showed discuss your eosinophia.

Cardiology: You have an appoint with [**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-9-18**] 2:20. The clinic is
located at [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 23**]
CLinical Center [**Location (un) 436**]. You should discuss the need for a
stress test to evaluate your heart disease at that time.



Completed by:[**2181-8-30**]
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Mitral valve insufficiency and aortic valve stenosis,Orthostatic hypotension,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of prostate,Tobacco use disorder,Unspecified essential hypertension'}


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: Shortness of Breath

PRESENT ILLNESS: The patient is a 79yo M with PMH of PE on coumadin, sytolic HF
(EF 35%), AS, Prostate CA, ETOH use who presented to OSH with
SOB and increased swelling of right leg with known DVT. + Cough
and ? low grade temps. AT [**Location (un) 620**], VS: T99.6, 107, [**11/2156**], 20,
93% 4L. LENI noted extension of DVT and patient was given
lovenox 100mg x 1. Also noted to have elevated troponin 0.33 and
BNP 10,190. Given lasix 10mg IV x 1. Also 1" nitropaste. Patient
then transfered to [**Hospital1 18**] for further management.
.
In the ED, VS: T 99.6 HR 107 BP 111/87 RR 20 93% on 4L. Patient
underwent CTA that showed interval improvement in previously
noted PEs with no new thrombi. Patient was given dose of
ceftriaxone, azithro for concern of pneumonia.
.
On review of systems, he denies any prior history of stroke,
TIA, bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.

MEDICAL HISTORY: # Dyslipidemia
# Hypertension
# Systolic heart failure- EF 35%
# Aortic stenosis- moderate to severe
# PE: junction right upper and right middle lob artery; also PE

MEDICATION ON ADMISSION: ASA 325mg daily
Coumadin
Lasix 20 daily
Lisinopril 2.5 daily
Simvastatin 10mg daily
Pantoprazole 40 PO daily
Ipatropium
Albuterol

ALLERGIES: Bacitracin

PHYSICAL EXAM: VS: T 98.2 BP 115/48 HR 65 RR 24 97%5L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: FAMILY HISTORY:
No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: Positive for alcohol and tobacco use: 6beers and 2 shots/day,
60pack year hx. Lives with his son. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic systolic heart failure,Mixed acid-base balance disorder,Acute kidney failure, unspecified,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Mitral valve insufficiency and aortic valve stenosis,Orthostatic hypotension,Other and unspecified alcohol dependence, continuous,Personal history of malignant neoplasm of prostate,Tobacco use disorder,Unspecified essential hypertension'}
