CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 76 year old woman with history of HTN, COPD and psychiatric
illness presenting with increased left breast size and worsening
dyspnea on exertion. Symptoms started approximately 5 days ago
and have progressed to where her left breast is 4-6 times larger
than her right breast. The dyspnea on exertion began ~2 days ago
(patient is unable to really recall at this point) and has
worsened, now including some symptoms even with just talking
(previously had some dyspnea with exertion). Reports some cough
across past few days, unclear if productive. She denies any
chest pain, fevers, nipple discharge or specific breast pain. No
trauma.
.
On arrival in the ED her initial VS were 97.5 119/71 72 20
98/4L. Left breast noted to be enlarged and mildly erythematous.
She was started on vancomycin with concern for cellulitis. CXR
was felt to be concerning for a LLL infiltrate and she was
started on levoquin for CAP. An EKG showed slow atrial
fibrilation. A bedside echocardiogram was performed which showed
a pericardial effusion.
.
Denies any chest pain, fevers, chills, night sweats, nausea,
vomiting, diarrhea, dizziness, light-headedness.

MEDICAL HISTORY: bipolar disorder
HTN
COPD
h/o EtOH abuse
h/o thiaside abuse (?)
h/o CVA
h/o endometrial Ca w/p TAH-BSO
h/o falls
degenerative disc disease of lumbar spine
atrial fibrillation

MEDICATION ON ADMISSION: -atenolol 100mg daily
-divalproex 750mg daily
-doxazosin 2mg daily
-lasix 20mg PO daily
-lisinopril 30mg daily
-mirtazapine 15mg QHS
-nifedipine ER 90mg daily
-ranitidine 150mg [**Hospital1 **]
-detrol 4mg QHS
-simvastatin 40mg daily
-trazadone 50mg qhs
-acetamenophen 500-1000mg Q6h prn

ALLERGIES: Paxil / Haldol

PHYSICAL EXAM: On admission
VS: 96.1 122/65 hr 107 rr 20 93%/3L
pulsus: 8 mm Hg (with doppler)
General: ill-appearing elderly woman in mild distress
Lungs: diffuse rhonci, minor wheeze
Heart: RRR, no R/G/M
Chest: Left breast larger than right with diffuse errythema,
mild warmth, no significant TTP, nipple WNL, no discharge, no
palpable masses
Extremities: 2+ LE edema, palpable distal pulses
Neuro: CNII-XII intact, alert, oriented to self, place and year
.
On discharge
General: Alert, oriented x 3, lethargic but arousable, no acute
distress, answers questions but can only provide "yes, no"
answers
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat on U/S sitting and upright, no LAD
Lungs: Crackles to lower [**2-5**] bilaterally in lateral fields,
scant wheezes in upper [**2-5**].  R crackles>L crackles
CV: Irreg, irreg; normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: LE's edematous and diffusely tender to touch, UE's
edematous.  Extremities wrapped with ACE bandages.  R hand
ecchymotic; well perfused, pulses difficult to palpate, but ext
warm bilaterally
Neuro: CN II-XII intact, moving all four extremities
spontaneously, strength difficult to assess due to lack of
cooperation and pain

FAMILY HISTORY: Grandmother positive breast cancer. Mother positive
hypertension. No family history of colon cancer. The patient
does not know father's side.

SOCIAL HISTORY: Widowed in [**2175**]. Has three children. Significant smoking
history: 1 pack per day x 40 years. Former alcohol abuse.
Intestinal infection due to Clostridium difficile,Other anomalies of larynx, trachea, and bronchus,Congestive heart failure, unspecified,Inflammatory disease of breast,Thrombocytopenia, unspecified,Bipolar disorder, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension,Atrial fibrillation,Deficiency of vitamin K,Do not resuscitate status,Other alteration of consciousness,Edema,Tobacco use disorder,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Pain in limb,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute kidney failure, unspecified
Int inf clstrdium dfcile,Laryngotrach anomaly NEC,CHF NOS,Inflam disease of breast,Thrombocytopenia NOS,Bipolar disorder NOS,Hx TIA/stroke w/o resid,Hypertension NOS,Atrial fibrillation,Deficiency of vitamin k,Do not resusctate status,Other alter consciousnes,Edema,Tobacco use disorder,Foreign body in larynx,Resp obstr-inhal obj NEC,Accid in resident instit,Pain in limb,Acute respiratry failure,Food/vomit pneumonitis,Nutritional marasmus,Obs chr bronc w(ac) exac,Hyposmolality,Coagulat defect NEC/NOS,Acute kidney failure NOS
Admission Date:  [**2192-10-16**]              Discharge Date:   [**2192-11-12**]

Date of Birth:  [**2115-10-30**]             Sex:   F

Service: MEDICINE

Allergies:
Paxil / Haldol

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Bronchoscopy


History of Present Illness:
76 year old woman with history of HTN, COPD and psychiatric
illness presenting with increased left breast size and worsening
dyspnea on exertion. Symptoms started approximately 5 days ago
and have progressed to where her left breast is 4-6 times larger
than her right breast. The dyspnea on exertion began ~2 days ago
(patient is unable to really recall at this point) and has
worsened, now including some symptoms even with just talking
(previously had some dyspnea with exertion). Reports some cough
across past few days, unclear if productive. She denies any
chest pain, fevers, nipple discharge or specific breast pain. No
trauma.
.
On arrival in the ED her initial VS were 97.5 119/71 72 20
98/4L. Left breast noted to be enlarged and mildly erythematous.
She was started on vancomycin with concern for cellulitis. CXR
was felt to be concerning for a LLL infiltrate and she was
started on levoquin for CAP. An EKG showed slow atrial
fibrilation. A bedside echocardiogram was performed which showed
a pericardial effusion.
.
Denies any chest pain, fevers, chills, night sweats, nausea,
vomiting, diarrhea, dizziness, light-headedness.


Past Medical History:
bipolar disorder
HTN
COPD
h/o EtOH abuse
h/o thiaside abuse (?)
h/o CVA
h/o endometrial Ca w/p TAH-BSO
h/o falls
degenerative disc disease of lumbar spine
atrial fibrillation

Social History:
Widowed in [**2175**]. Has three children. Significant smoking
history: 1 pack per day x 40 years. Former alcohol abuse.


Family History:
Grandmother positive breast cancer. Mother positive
hypertension. No family history of colon cancer. The patient
does not know father's side.


Physical Exam:
On admission
VS: 96.1 122/65 hr 107 rr 20 93%/3L
pulsus: 8 mm Hg (with doppler)
General: ill-appearing elderly woman in mild distress
Lungs: diffuse rhonci, minor wheeze
Heart: RRR, no R/G/M
Chest: Left breast larger than right with diffuse errythema,
mild warmth, no significant TTP, nipple WNL, no discharge, no
palpable masses
Extremities: 2+ LE edema, palpable distal pulses
Neuro: CNII-XII intact, alert, oriented to self, place and year
.
On discharge
General: Alert, oriented x 3, lethargic but arousable, no acute
distress, answers questions but can only provide "yes, no"
answers
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat on U/S sitting and upright, no LAD
Lungs: Crackles to lower [**2-5**] bilaterally in lateral fields,
scant wheezes in upper [**2-5**].  R crackles>L crackles
CV: Irreg, irreg; normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: LE's edematous and diffusely tender to touch, UE's
edematous.  Extremities wrapped with ACE bandages.  R hand
ecchymotic; well perfused, pulses difficult to palpate, but ext
warm bilaterally
Neuro: CN II-XII intact, moving all four extremities
spontaneously, strength difficult to assess due to lack of
cooperation and pain

Pertinent Results:
CBC
[**2192-11-12**] 06:55AM BLOOD WBC-8.1 RBC-2.74* Hgb-9.2* Hct-29.6*
MCV-108* MCH-33.4* MCHC-30.9* RDW-22.6* Plt Ct-364
[**2192-11-11**] 06:40AM BLOOD WBC-8.7 RBC-2.89* Hgb-9.4* Hct-31.0*
MCV-108* MCH-32.5* MCHC-30.2* RDW-22.5* Plt Ct-404
[**2192-11-10**] 06:20AM BLOOD WBC-7.3 RBC-2.83* Hgb-9.3* Hct-30.5*
MCV-108* MCH-32.8* MCHC-30.4* RDW-22.3* Plt Ct-444*

Chemistry
[**2192-11-12**] 06:55AM BLOOD Glucose-109* UreaN-25* Creat-0.9 Na-143
K-4.9 Cl-114* HCO3-22 AnGap-12
[**2192-11-11**] 06:40AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-143
K-5.1 Cl-114* HCO3-23 AnGap-11
[**2192-11-10**] 06:20AM BLOOD Glucose-104* UreaN-31* Creat-1.0 Na-144
K-5.2* Cl-116* HCO3-23 AnGap-10

Troponins
[**2192-10-16**] 11:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2192-10-16**] 03:50PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-8869*

TSH
[**2192-10-19**] 06:45AM BLOOD TSH-1.5

HIT antibodies
[**2192-10-19**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES-negative

Miscellaneous:
[**2192-10-25**] 05:50AM BLOOD Ret Aut-1.1*
[**2192-10-25**] 05:50AM BLOOD ACA IgG-10.0 ACA IgM-6.2
[**2192-10-25**] 05:50AM BLOOD Lupus-POS
[**2192-10-31**] 05:38AM BLOOD ALT-7 AST-15 CK(CPK)-19*
[**2192-10-25**] 03:57PM BLOOD Lipase-12
[**2192-11-12**] 06:55AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
[**2192-10-31**] 05:38AM BLOOD VitB12-1502*
[**2192-10-24**] 10:23AM BLOOD D-Dimer-892*
[**2192-10-18**] 06:50AM BLOOD calTIBC-251* Ferritn-107 TRF-193*

Urine:
[**2192-11-8**] 12:19PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.026
[**2192-11-8**] 12:19PM URINE Blood-LG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2192-11-8**] 12:19PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-RARE
Epi-0
[**2192-11-7**] 07:59PM URINE CastHy-[**7-12**]*
[**2192-10-26**] 04:48AM URINE Hours-RANDOM UreaN-636 Creat-94 Na-11
K-60 Cl-LESS THAN
[**2192-10-17**] 05:37AM URINE Osmolal-321
URINE CULTURE (Final [**2192-11-9**]):    NO GROWTH.
URINE CULTURE (Final [**2192-11-7**]): YEAST.    ~6OOO/ML

Microbiology:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-10-24**]): FECES
POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
Blood Culture, Routine (Final [**2192-10-31**]):    NO GROWTH.

TTE ([**2192-10-17**])
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is a small circumferential
pericardial effusion without echocardiographic signs of
tamponade.

Compared with the report of the prior study (images unavailable
for review) of [**2185-9-5**], the right ventricular cavity is now
dilated and severe pulmonary artery systolic hypertension is now
present. The severity of tricuspid regurgitation is also
increased and a small circumferential pericardial effusion is
now present.

Mammogram ([**2192-10-18**])
IMPRESSION:
1. Diffuse left breast skin and trabecular thickening with
associated diffuse edema of the left breast tissue. No evidence
of pathologically enlarged left axillary nodes. Differential
considerations would include fluid overload related to
congestive heart failure (unilateral in this patient who states
that she preferentially sleeps with her left side down),
mastitis, or a diffuse infiltrative process such that can be
seen with inflammatory breast cancers or lymphoma. Clinical
correlation is advised and any decision to biopsy at this time
should be based on the clinical assessment.

CT Chest w/o contrast ([**2192-10-26**])
FINDINGS: The thyroid gland is unremarkable. There is extensive
atherosclerotic calcification involving the arch of the aorta
and coronary arteries. There is moderate-to-severe cardiomegaly
with a small pericardial effusion. Numerous mediastinal lymph
nodes measure up to 8 mm in short axis diameter are present. No
axillary or hilar lymphadenopathy.

In the tracheobronchial tree, there is moderate narrowing of the
trachea and more severe narrowing of the bronchial tree,
particularly on the left, due to bronchomalacia, compounded by
extensive mucous plugging progressively increasing distal to the
left main stem bronchus, occluding the left lower lobe bronchus,
resulting in left lower lobe collapse. The left upper lobe and
lingular bronchi are clear. There is a trace left pleural
effusion.

Bilateral coarse reticulation occuring predominantly in the
subpleural region, with areas of honeycombing particularly along
the right major fissure, is consistent with moderately severe
chronic interstitial lung disease, partially fibrotic. Diffusely
increased density of the right lung when compared to the left,
and thickening of its interlobular septa is likely asymmetric
pulmonary edema. No evidence of pneumonia. There is no
pneumothorax.

The thoracic aorta is of normal caliber, however, there is area
of fusiform dilatation within the abdominal aorta measuring up
to 3.4 cm (400B, 29). Area of linear calcification which appears
medially displaced from the left lateral wall in the aorta at
this level may represent sequelae of a penetrating ulcer or
pseudointimal calcification of mural thrombus. Evaluation is
limited due to lack of IV contrast. Limited views of the upper
abdomen demonstrate
bilateral renal cysts which are partially imaged.

BONE WINDOWS: There are no suspicious osseous lesions.
Multilevel
degenerative changes of the thoracic spine are present.

IMPRESSION:
1. Tracheobronchomalacia, worse on the left, probably
predisposes to
extensive mucous plugging of the left lower lobe bronchus and
lower lobe
collapse.
2. Chronic, moderately severe fibrosing, interstitial lung
disease. Asymmetric pulmonary edema.
3. Moderate-to-severe cardiomegaly, small pericardial effusion.
4. Mild aneurysmal dilatation of the abdominal aorta measuring
up to 3.4 cm.

Ultrasound abdomen ([**2192-10-29**])
IMPRESSION:
1. Patent hepatic vasculature with no portal vein thrombosis
identified.
2. Trace of ascites.
3. Multiple bilateral simple renal cysts.

CXR ([**2192-11-4**])
FINDINGS: As compared to the previous examination, there is no
relevant
change. The left PICC line ends in the left brachiocephalic
vein, as on the previous study. No other changes. Moderate
cardiomegaly, minimal increase in lung density at the bases of
the right upper lobe, no evidence of pleural effusions.

Brief Hospital Course:
76 yo female with history of HTN and COPD who initially
presented from her senior living center with left mastitis, but
developed SOB and hypoxia on arrival to the medicine floor felt
to be from CHF exacerbation. Hospitalization complicated by
pneumonia, Afib with RVR, Clostridium difficile colitis, low
urine output, severe anasarca, low nutrition status, delirium,
and risk of aspiration.

#. Mastitis: Patient initially presented with swelling of left
breast.  Mammogram showed left breast edema c/w CHF vs. mastitis
vs. inflammatory breast cancers or lymphoma.  Rash and edema
resolved with bactrim and cefazolin.  No pathologically enlarged
left axillary nodes were seen on mammogram. Patient asked to
continue to discuss further outpatient repeat imaging and
screening schedule with primary care

#. Hypoxia/Aspiration/Hospital Aquired Pneumonia: The patient
had marked clinical concern upon arrival to the medical floor
because she had hypoxia to 80% on 2L nasal cannula. This
desaturation and shortness of breath was felt to be due to
aspiration event.  Patient was transferred to the MICU for
several days of close monitoring.  CXR showed LLL opacity.
Bronchoscopy was performed and significant for mucus plugging,
plugging was relieved with improvement of her hypoxia.  She was
also treated for hospital aquired pneumonia, and completed a 7
day course of IV vancomycin and a IV ceftazidime.  Her
respiratory status has improved to the point where she saturates
in the mid to high 90's on room air, but is more stable in the
mid-90s on 2L NC continuously. She may drop to high 80s without
nasal cannula.  Also, with any administration of aggressive IV
fluids, she tends to third spaces/accumulate additional fluid
into her lungs and can desaturate.

#. Clostridium difficile colitis: Patient developed diarrhea
soon after getting several antibiotics for her left
mastitis/cellulitis. Stool studies were positive for Clostridium
difficile. She was treated initially with PO vancomycin and IV
metronidazole with improvement of her symptoms.  Antibiotics
were later narrowed to include just PO vancomycin liquid at
125mg q6hrs . She will need to complete another 3 days of PO
vancomycin which is to be completed on [**2192-11-15**]. PLEASE reassess
if still having diarrhea after completing antibiotics.

#. Thrombocytopenia: During her hospital course the patient was
also noted to be thrombocytopenic and she was evaluated by
heme/oncology service. Several ongoing studies and clinical
trend revealed that she was not thrombocytopenia due to
DIC/TTP/HUS.  PF4 antibodies were negative for HIT.
Thrombocytopenia was ultimately attributed to Bactrim. Platelet
count recovered following discontinuation of Bactrim and has
remained within normal limits.

#. Atrial fibrillation: Inpatient team spoke with PCP who
reports that the patient is in chronic A fib, although she has
never required rate control in the past and had not been on
anticoagulation.  HR prior to hospitalization had been in the
70-80s.  On this admission, patient was very difficult to
diurese, each time an attempt was made at diursing her, she
would have A fib with RVR, likely a reflection of being so
intravascularly depleted despite looking grossly anasarcic.
Patient was started on PO diltiazem with good control of her
rate which remains in the 70-80s range predominantly. Patient
had never been on warfarin anticoagulation for a history of
falls.

#. CHF/Anasarca: She has a history of CHF, although unclear what
her EF was prior to this admission.  TTE on this admission
showed preserved EF of >55%.  Patient was grossly anasarcic on
this admission, likely due to both CHF as well as low albumin
(near 2.0). Attempts were made to diurese her but it would
trigger Afibrillation with RVR. In order to help mobilize her
third spaced fluids, PO nutrition was encouraged, and ACE wraps
were utilized to help in encouraging fluids to return to
intravascular space.  On discharge, the edema in her arms and
legs are much improved, but she would likely benefit from
further use of ACE wraps to provide compression to her arms and
legs. She was also started on additional triamcinlone cream to
try to help with some stasis skin changes/pain associated with
severe anasarca and poor circulation issues.

#. Pain: Unclear what the exact etiology of her pain is, but she
describes a vague pain in both her legs as well as her arms at
times.  Likely due to the edematous state that they are in given
her very extreme anasarca. She was initially given morphine for
the pain but transitioned to low dose oxycodone by discharge. As
above, she was also started on triamcinalone cream to help with
stasis skin changes/severe anasarca discomfort. She has done
very well and requires only minimal amounts of oxycodone for
pain control.

#. COPD: Longstanding history of COPD on admission.  She was put
on ipratropium and albuterol nebs.  Her desaturations (see
above) were attributed more to her pulmonary edema/pneumonia
rather than to her COPD history.  On discharge her respiratory
status is stable, doing well on 2L nasal cannula with
saturations above >95% range. She will plan to continue
albuterol nebs PRN at rehab, daily Advair and will also continue
her daily nicotine patch as well. Please continue to wean oxygen
further if she tolerates.

#. Nutritional status: Patient with low albumin of 2.0, which
likely exacerbated her edema/anasarca.  Per family, patient does
not eat much at baseline.  Speech and swallow evaluated the
patient and found her to aspirate on thin liquids.  During this
hospitalization she was maintained on a ground solid and nectar
thickened diet, but took very limited amounts of food PO.  She
needs someone to actively encourage her to eat.  Two attempts
were made in the ICU to place a dobhoff but patient was unable
to tolerate placement of a feeding tube.  Given her anasarca,
our hope was to give her more nutrition to increase her albumin
to help in mobilizing third spaced fluids, however both patient
and family did not want a feeding tube or PEG tube to be placed.
 Nutrition being supplemented with thiamine, MVI, and Vitamin
B12.

#. Goals of care: In the week prior to her discharge, a family
meeting was called.  With the help of social worker, patient
named her sons as her HCPs.  She was made DNR/DNI.  It was
established by the patient and family that they did not want to
have any escalation of care.  The decision was also made that
they would not pursue a feeding tube for nutrition should her
nutritional status deteriorate further.

#. Delirium/Bipolar Disorder: Intermittently delirious on this
admission likely from pain vs. polypharmacy issues at times.
Once pain was under control, patient was much more lucid and
could hold short conversations.  She also has a history of
bipolar disorder for which psychiatry was consulted.  Since all
her home meds had been held during her ICU stay, psychiatry
thought it prudent to give her medications back slowly given her
delirium.  Divalproex was restarted (sprinkles form at 250mg at
each meal for 750mg daily dose) and most recent level within
normal limits.  Risperdal was recommended to be used prn for
agitation but she did not require any risperdal during her
hospital course. Patient may need to be restarted on her usual
pre-admission psychiatric medications that include 15mg
mirtazapine qhs and 50mg trazodone qhs. If possible, please
discuss with psychiatrist while at rehabilitation.

#. Acute renal failure/Oliguria: Despite being anasarcic,
patient was overwhelmingly intravascularly dry.  JVP is flat.
She had very poor urine output while in the ICU.  Renal labs
showed that she was incredibly prerenal.  Her BUN and creatinine
would improve with administration of IVF, however given her poor
nutritional status, it would also cause for her to have more
pulmonary edema and extremity edema.  On call out to the floor,
IVF's were very cautiously given during brief periods of
hypernatremia (Na peaked at 148-->143 by discharge), but
otherwise PO intake was encouraged.  An albumin challenge was
also tried, but with only marginal increase in her urinary
output.  Her urine output has gradually improved over the course
of her stay on the medicine floors, averaging 300-500 cc/day.
U/A consistently showed dirty urine with leuks, WBCs, and few
bacteria.  Urine culture at one point showed scant amount of
yeast but otherwise showed no growth.  Dirty UA was attributed
to the fact that her urine was so concentrated and she was not
treated for UTI given no new leukocytosis, fevers or other
clinical complaints of suprapubic pain, dysuria or urgency.

Medications on Admission:
-atenolol 100mg daily
-divalproex 750mg daily
-doxazosin 2mg daily
-lasix 20mg PO daily
-lisinopril 30mg daily
-mirtazapine 15mg QHS
-nifedipine ER 90mg daily
-ranitidine 150mg [**Hospital1 **]
-detrol 4mg QHS
-simvastatin 40mg daily
-trazadone 50mg qhs
-acetamenophen 500-1000mg Q6h prn


Discharge Medications:
1. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for  pain.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. triamcinolone acetonide 0.1 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for dermatitis changes/leg
pains.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed for constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal every twenty-four(24) hours as needed for request.
9. therapeutic multivitamin     Liquid Sig: One (1) Tablet PO
DAILY (Daily).
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule,
Sprinkle PO TID (3 times a day).
12. vancomycin 125 mg Capsule Sig: One (1) LIQUID 125mg PO Q6H
(every 6 hours) for 3 days: ORAL LIQUID FORM PLEASE .
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for sob, wheeze.
14. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
16. white petrolatum-mineral oil     Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
17. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): aplly to sacral area .
18. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO AS DIRECTED :
give [**2-4**] tablet x 1 pre-transport or when moving patient .
19. Anasarca Ace Wraps
-Daily ACE wraps over full length of both upper and lower
extremities for severe anasarca


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
Primary:
Left breast mastitis
Hospital acquired pneumonia
C.diff colitis
Acute renal failure
Aspiration risk

Secondary:
Atrial fibrillation
COPD
Bipolar disease
HTN


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
It was a pleasure taking care of you in the hospital.  You were
initially admitted with concern for a skin infection on the left
 breast called mastitis/cellulitis in addition to shortness of
breath and a cough which was felt to be from a flare up of your
known congestive heart failure.

You were given medications called diuretics and your heart
failure symptoms slowly resolved. You were also treated with
antibiotics and your breast infection improved. However, in the
setting of multiple antibiotics you developed a diarrhea
infection called C.difficile colitis.  You were put on
antibiotics for this infection and will finish the course at the
[**Hospital3 2558**].

You also developed pneumonia while you were with us and were
treated with antibiotics for this as well.  Also during your
stay, you had difficulty swallowing and would aspirate.  You
were put on a pureed nectar-thickened diet for this.  Your
nutritional status remained poor because you ate very little
during your hospital course.  Your low level of proteins made
the swelling in your arms and legs difficult to get rid of. The
nutrition team saw you in the hospital and you have been placed
on several vitamin supplements and nutritional shakes to enhance
your caloric intake.

You will be going to a rehab facility where doctors, nurses, and
physical therapists will be able to help you with all these
issues.

Please see your complete medication list and instructions below.


MEDICATION INSTRUCTIONS /CHANGES:

The following medications that you were taking prior to
admission have been DISCONTINUED: atenolol, doxazosin, lasix,
lisinopril, nifedipine, detrol, mirtazapine and trazodone.

Please CONTINUE taking the following medications you were taking
prior to admission:
-Depakote 750mg daily (now in sprinkle forms with meals*, 250mg
per meal*)
-Ranatidine 150mg tablet twice daily
-Simvastatin 40mg tablet once daily
-Tylenol 650mg tablet q6 hours as needed

The following NEW MEDICATIONS have been started while you were
in the hospital:
-triamcinalone cream applied to extremities twice daily
-Hydrocerin/mineral oil cream applied twice daily to extremities

-fluticasone-salmeterol 250/50mcg inhaler twice daily
-albuterol nebulizers q4 hours as needed
-thiamine 100mg tablet daily
-multivitamin tablet daily
-oxycodone 5mg q6 hours as needed for pain (also: 2.5mg x 1 dose
as needed when moving or transporting the patient)
-heparin SC three times daily for DVT prevention
-vitamin b12 50mcg daily ([**2-4**] 100mcg tablet)
-Vancomycin 125mg liquid q6 hours for 3 more days (discontinue
[**2192-11-15**])
-2% miconazole powder -apply twice daily to sacral area
-Senna/Colace as needed for any constipation

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] after you are discharged from
rehab, at the [**2192**] office. [**Telephone/Fax (1) 30837**].

*Please discuss the need for additional breast cancer screening
(mammography) with your primary care physician as sometimes
surface skin changes on the breast can be a warning sign for
early breast cancers.
{'Intestinal infection due to Clostridium difficile,Other anomalies of larynx, trachea, and bronchus,Congestive heart failure, unspecified,Inflammatory disease of breast,Thrombocytopenia, unspecified,Bipolar disorder, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension,Atrial fibrillation,Deficiency of vitamin K,Do not resuscitate status,Other alteration of consciousness,Edema,Tobacco use disorder,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Pain in limb,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute kidney failure, unspecified'}


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: 76 year old woman with history of HTN, COPD and psychiatric
illness presenting with increased left breast size and worsening
dyspnea on exertion. Symptoms started approximately 5 days ago
and have progressed to where her left breast is 4-6 times larger
than her right breast. The dyspnea on exertion began ~2 days ago
(patient is unable to really recall at this point) and has
worsened, now including some symptoms even with just talking
(previously had some dyspnea with exertion). Reports some cough
across past few days, unclear if productive. She denies any
chest pain, fevers, nipple discharge or specific breast pain. No
trauma.
.
On arrival in the ED her initial VS were 97.5 119/71 72 20
98/4L. Left breast noted to be enlarged and mildly erythematous.
She was started on vancomycin with concern for cellulitis. CXR
was felt to be concerning for a LLL infiltrate and she was
started on levoquin for CAP. An EKG showed slow atrial
fibrilation. A bedside echocardiogram was performed which showed
a pericardial effusion.
.
Denies any chest pain, fevers, chills, night sweats, nausea,
vomiting, diarrhea, dizziness, light-headedness.

MEDICAL HISTORY: bipolar disorder
HTN
COPD
h/o EtOH abuse
h/o thiaside abuse (?)
h/o CVA
h/o endometrial Ca w/p TAH-BSO
h/o falls
degenerative disc disease of lumbar spine
atrial fibrillation

MEDICATION ON ADMISSION: -atenolol 100mg daily
-divalproex 750mg daily
-doxazosin 2mg daily
-lasix 20mg PO daily
-lisinopril 30mg daily
-mirtazapine 15mg QHS
-nifedipine ER 90mg daily
-ranitidine 150mg [**Hospital1 **]
-detrol 4mg QHS
-simvastatin 40mg daily
-trazadone 50mg qhs
-acetamenophen 500-1000mg Q6h prn

ALLERGIES: Paxil / Haldol

PHYSICAL EXAM: On admission
VS: 96.1 122/65 hr 107 rr 20 93%/3L
pulsus: 8 mm Hg (with doppler)
General: ill-appearing elderly woman in mild distress
Lungs: diffuse rhonci, minor wheeze
Heart: RRR, no R/G/M
Chest: Left breast larger than right with diffuse errythema,
mild warmth, no significant TTP, nipple WNL, no discharge, no
palpable masses
Extremities: 2+ LE edema, palpable distal pulses
Neuro: CNII-XII intact, alert, oriented to self, place and year
.
On discharge
General: Alert, oriented x 3, lethargic but arousable, no acute
distress, answers questions but can only provide "yes, no"
answers
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat on U/S sitting and upright, no LAD
Lungs: Crackles to lower [**2-5**] bilaterally in lateral fields,
scant wheezes in upper [**2-5**].  R crackles>L crackles
CV: Irreg, irreg; normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: foley in place
Ext: LE's edematous and diffusely tender to touch, UE's
edematous.  Extremities wrapped with ACE bandages.  R hand
ecchymotic; well perfused, pulses difficult to palpate, but ext
warm bilaterally
Neuro: CN II-XII intact, moving all four extremities
spontaneously, strength difficult to assess due to lack of
cooperation and pain

FAMILY HISTORY: Grandmother positive breast cancer. Mother positive
hypertension. No family history of colon cancer. The patient
does not know father's side.

SOCIAL HISTORY: Widowed in [**2175**]. Has three children. Significant smoking
history: 1 pack per day x 40 years. Former alcohol abuse. 

### Response:
{'Intestinal infection due to Clostridium difficile,Other anomalies of larynx, trachea, and bronchus,Congestive heart failure, unspecified,Inflammatory disease of breast,Thrombocytopenia, unspecified,Bipolar disorder, unspecified,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension,Atrial fibrillation,Deficiency of vitamin K,Do not resuscitate status,Other alteration of consciousness,Edema,Tobacco use disorder,Foreign body in larynx,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation,Accidents occurring in residential institution,Pain in limb,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Obstructive chronic bronchitis with (acute) exacerbation,Hyposmolality and/or hyponatremia,Other and unspecified coagulation defects,Acute kidney failure, unspecified'}
