Acute on chronic combined systolic and diastolic heart failure Other diseases of trachea and bronchus Congestive heart failure unspecified Hypertensive chronic kidney disease unspecified with chronic kidney disease stage I through stage IV or unspecified Chronic kidney disease Stage II (mild) Chronic airway obstruction not elsewhere classified Coronary atherosclerosis of native coronary artery Occlusion and stenosis of carotid artery without mention of cerebral infarction Occlusion and stenosis of multiple and bilateral precerebral arteries without mention of cerebral infarction Other specified forms of chronic ischemic heart disease Other and unspecified hyperlipidemia Peripheral vascular disease unspecified Atherosclerosis of renal artery Depressive disorder not elsewhere classified Panic disorder without agoraphobia Other postprocedural status
 
Name:  ___.             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Amoxicillin
 
Attending: ___
 
Chief Complaint:
shortness of breath
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ y/o woman with h/o panic attacks, carotid artery stenosis, 
hypertension, hyperlipidemia, COPD (on 2.5L home 02 and daily 
prednisone), CAD, CHF with EF 10%(per OSH report) who presented 
with shortness of breath. She noted swelling in her legs (L >R) 
yesterday and felt herself gasping for breath, she took her home 
po dose of lasix and the swelling improved but the SOB persisted 
so she came to our ED. Of note, she has multiple recent 
admissions at ___ with the same complaint, and each 
time she was diuresed and sent home. 
 
Past Medical History:
1. Carotid artery stenosis status post bilateral endarterectomy 
in ___ now with recurrent stenosis. 
2. Chronic Obstructive Pulmonary Disease on home oxygen at 2.5L 
at night.
3. Severe peripheral vascular disease.
4. Hypertension
5. Hyperlipidemia
6. Right renal artery stenosis
7. Abdominal aortic aneurysm, s/p surgery ___
8. Status post left eye cataract surgery. 
9. Right eye cataract (untreated)
10. History of panic attacks
11. Congestive Heart Failure, reported EF 10%

 
Social History:
___
Family History:
Her father died of a myocardial infarction at the age of ___.
 
Physical Exam:
VS - 98.0, 147/93, 110, 18, 99%RA  
Gen: female 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 8-10 cm.  
CV: PMI located in ___ intercostal space, midclavicular line. 
RR, normal S1, S2. ___ systolic murmur. No thrills, lifts. No S3 
or S4.  
Chest: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use. diminished BS 
bilaterally; no crackles, wheezes or rhonchi.  
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by 
palpation. No abdominial bruits.  
Ext: 1+ bilateral ankle edema  
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.  
.  
Pulses:  
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+  

 
Brief Hospital Course:
In the ED, she was tachycardic, received 250 cc bolus without 
much improvement of her HR. CTA was negative for PE. She 
appeared clinically euvolemic; CXR without significant pulm 
edema, no JVD, no ___ swelling. LLE US without DVT. She was also 
reported to have low grade temp in the ED, and received 
levofloxacin x 1.  
.  
On arrival to the floor, she denied chest pain, shortness of 
breath, she is not tachycardic and notes that her legs are not 
edematous.  She had 02 sats of >95% on her home 02. 
.
#. Dyspnea: Occured in the setting of volume overload ___ edema) 
and mildly elevated troponins (0.06). However, acute MI ruled 
out, and patient clinically euvolemic throughout hospitalization 
except for some ankle swelling. BNP of 27000. CTA ruled out PE.  
She was restarted on her home dose of lasix. She was also 
started on ipatropium nebs  and albuterol nebs PRN and did not 
have any more shortness of breath or oxygen requirement.  Repeat 
Echo showed EF ___. We ordered a CT trachea that showed 
severe tracheobronchomalacia, and our internventional 
pulmonologists performed bronchoscopy.  The first bronchoscopy 
showed severe tracheomalacia and very large trachea.  They were 
unable to place the non-metal stent because it was too small.  
So they repeated the bronchoscopy the following day under 
sedation and placed a metal stent in her left mainstem bronchus 
and another metal stent in the trachea.  The patient tolerated 
the procedure well. She had mild cough with some sore throat 
after the procedure.
.  
#. CAD: No chest pain here, no evidence of MI. We increased her 
beta blocker from 25 to 50 po daily, continued her ACE and 
Statin.  We started Aspirin.  
.
#. Pump: EF reportedly 10% from OSH records. Echo here showed EF 
___.  We continued her home lasix. After discussion with our 
cardiologists, we did not feel she would benefit from ICD. 
Patient required a lot of education regarding diet, exercize and 
course of illness regarding her CHF. We also consulted nutrition 
for education about low salt, fluid restricted diet as well as 
general nutrition to keep up body mass.
.  
#. Hypertension: Well controlled on increased dose of 
metoprolol, and home dose of quinapril.  The patient did not 
have any episodes of hypo- or hypertension here.  
.  
# COPD: Dyspnea was unlikely to be COPD flare as patient 02 sat 
>92% on home 02, no wheezing on exam. We continued her home 02 
(2L) and her 02 sats remained >95%.  We started her on 
ipatropium and albuterol nebs and continued her prednisone. 
.  
#. Hyperlipidemia:  Continued simvastatin.  
.  
# Depression:  Continued home citalopram and nortriptyline.  
Arranged home services including social work, physical therapy 
and skilled nursing to help patient cope at home.  
.
 
Medications on Admission:
Simvastatin 20mg  
Citalopram 20mg QD  
Toprol 25mg daily  
Nortriptyline 50mg QD  
Protonix 40mg QD  
Furosemide 40mg QD  
Quinapril 40mg QD  
Prednisone 15 mg daily  

 
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).  
3. Prednisone 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).  
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr 
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*1 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) 
puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*5*
8. outpatient pulmonary rehab
Please go for outpatient pulmonary rehab
9. Quinapril 40 mg Tablet Sig: One (1) Tablet PO once a day.  
10. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO at 
bedtime.  
11. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.  

12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for 
Nebulization Sig: One (1) puff Inhalation Q6H (every 6 hours) as 
needed for shortness of breath.  
13. Polyethylene Glycol 3350 100 % Powder Sig: One (1)  PO once 
a day as needed.  
14. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO BID (2 
times a day) as needed for cough.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
___ Diagnosis:
Primary Diagnosis:
Acute systolic heart failure on chronic systolic heart failure
COPD
Hypertension
Anxiety
Secondary Diagnosis:
Hyperlipidemia 
h/o panic attacks

 
Discharge Condition:
stable

 
Discharge Instructions:
You came to the hospital with shortness of breath and a high 
heart rate.  We believe your shortness of breath was due to some 
fluid in your lungs and worse because you have underlying lung 
disease.  We treated you by putting you back on your home dose 
of lasix and increasing you toprol XL to slow down your heart 
rate.  We repeated an ultrasound of your heart and it showed 
that your heart function has not worsened.  We got a CT of your 
chest and trachea that showed your trachea is dilated and 
floppy.  We consulted our pulmonologists who performed a 
bronchoscopy and they placed two metal stents in your trachea. 
.
We made the following changes to your medication:
Changed Toprol XL 50 per day (up from 25 per day)
Added Aspirin 81 mg po daily
Added Ipatropium inhaler
Please take your lasix as directed, 40mg po daily
.
Because you have heart failure,
Please limit your fluid intake to 2L daily.
Please limit your salt intake
Please weigh yourself daily and if your weight increaes >3lbs 
call your doctor.
.
Please follow up with your doctor as below.
.
If you feel increasing short of breath, have swelling in your 
legs, have chest pain, dizziness, nausea, vomiting, fever, 
chills, or any other symptoms that are concerning to you please 
call your doctor or come to the emergency room.
 
Followup Instructions:
___

{'shortness of breath': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'swelling in legs': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'gasping for breath': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'tachycardic': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'low grade temp': [], 'dyspnea': ['Other diseases of trachea and bronchus'], 'mildly elevated troponins': ['Acute on chronic combined systolic and diastolic heart failure', 'Congestive heart failure'], 'severe tracheobronchomalacia': ['Other diseases of trachea and bronchus'], 'cough': ['Chronic airway obstruction'], 'sore throat': [], 'hypo- or hypertension': ['Hypertensive chronic kidney disease'], 'anxiety': ['Depressive disorder', 'Panic disorder without agoraphobia']}