CHIEF COMPLAINT: Shortness of breath.

PRESENT ILLNESS: This is a 54 year old gentleman
with multiple medical problems including coronary artery
disease, congestive heart failure, prosthetic mitral valve
placement.  The patient was admitted with shortness of breath
and pulmonary edema.  The patient was status post mitral
valve replacement and tricuspid valve replacement,
pericardial stripping on [**2123-8-10**].  He had a prolonged
postoperative course complicated by failure to wean from
ventilator with tracheostomy and percutaneous endoscopic
gastrostomy tube placement and Methicillin resistant

MEDICAL HISTORY: 1.  Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent in [**4-1**].
2.  Congestive heart failure.
3.  Status post mitral valve replacement and tricuspid valve
replacement [**2123-8-10**].
4.  AICD [**4-1**].
5.  History of cerebrovascular accident secondary to coronary
artery disease, residual left finger numbness.
6.  History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical discectomy.
9.  History of nasal treatment.
10. Tracheostomy [**2123-8-25**].
11. Gastrostomy tube placement [**2123-8-25**].
12. Methicillin resistant Staphylococcus aureus pneumonia
diagnosed [**2123-9-2**].
13. Constrictive pericarditis.
14. Iron deficiency anemia.

MEDICATION ON ADMISSION: 1.  Amiodarone 400 mg q.d.
2.  Captopril 6.25 mg q.d.
3.  Thyroxine 125 mcg q.d.
4.  Potassium Chloride 10 meq q.d.
5.  Ranitidine 150 mg q.d.
6.  Oxazepam q.h.s.
7.  Coumadin.
8.  Lasix 60 mg q.d.
9.  Lovenox 60 mg subcutaneous b.i.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died from colon cancer.  No history
of coronary artery disease.

SOCIAL HISTORY: The patient is married.  He does not smoke
or drink alcohol.  He currently lives in [**Hospital1 **]
Rehabilitation Center.
Congestive heart failure, unspecified,Unspecified pleural effusion,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Unspecified septicemia,Paroxysmal ventricular tachycardia,Aortic valve disorders,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Heart valve replaced by other means
CHF NOS,Pleural effusion NOS,Meth sus pneum d/t Staph,Hematoma complic proc,Septicemia NOS,Parox ventric tachycard,Aortic valve disorder,Hdgk dis unsp xtrndl org,Heart valve replac NEC
Admission Date:  [**2123-9-20**]     Discharge Date:  [**2123-10-14**]

Date of Birth:   [**2069-5-9**]     Sex:  M

Service:

ADDENDUM:  Mr. [**Known lastname **] continued to improve from a
cardiovascular and respiratory standpoint.  His dopamine was
initially discontinued with a Lasix drip and dobutamine drip
continued.  He diuresed well at 800 cc to 1000 cc per day.
The Lasix drip was switched to a bolus regimen of 100 mg
intravenously q.8h. and eventually to 80 mg intravenously
q.8h. with a consistent diuresis of 200 cc to 500 cc per day.
The dobutamine drip was discontinued on [**11-29**] with
systolic pressures in the low 100 range.  His renal function
continued to do well.  He underwent extension of his
gastrostomy tube to a post pyloric jejunostomy tube without
incident.  On [**11-29**], his trachea was extended in a
percutaneous fashion to a bypass granuloma tissue on the
anterior aspect of the trachea diagnosis on bronchoscopy on
[**11-29**].  He now is able to ventilate considerably better.
His ventilator was ultimately weaned to a pressure support of
between 10 and 12 with a PEEP of 10, and an FIO2 of 0.4,
pulling in volumes of 300 cc to 400 cc per breath.  His
mental status continued to clear to his baseline; however, he
appeared more depressed than usual, and per Psychiatric
consultation was started on Celexa at 10 mg p.o. q.d. to be
advanced 20 mg p.o. q.d.   His renal function continued to
remain stable with a creatinine of 0.9 to 1.  His edema
resolved impressively with minimal pitting edema below the
knee, 1+ above the knee, and 2+ in the presacral region.  He
was maintained on Lovenox for anticoagulation with regard to
his valves.

MEDICATIONS ON DISCHARGE:   Will be dictated in a second
addendum.

DISCHARGE STATUS:  Will be dictated in a second addendum.

CONDITION AT DISCHARGE:  Will be dictated in a second
addendum.



                          [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7169**]

Dictated By:[**Last Name (NamePattern4) 98138**]

MEDQUIST36

D:  [**2123-11-30**]  17:44
T:  [**2123-11-30**]  15:51
JOB#:  [**Job Number **]



RP [**2123-12-6**]


Admission Date:  [**2123-9-20**]     Discharge Date:  [**2123-10-14**]

Date of Birth:   [**2069-5-9**]     Sex:  M

Service:

ADDENDUM:  Mr. [**Known lastname **] continued to improve from a
cardiovascular and respiratory standpoint.  His dopamine was
initially discontinued with a Lasix drip and dobutamine drip
continued.  He diuresed well at 800 cc to 1000 cc per day.
The Lasix drip was switched to a bolus regimen of 100 mg
intravenously q.8h. and eventually to 80 mg intravenously
q.8h. with a consistent diuresis of 200 cc to 500 cc per day.
The dobutamine drip was discontinued on [**11-29**] with
systolic pressures in the low 100 range.  His renal function
continued to do well.  He underwent extension of his
gastrostomy tube to a post pyloric jejunostomy tube without
incident.  On [**11-29**], his trachea was extended in a
percutaneous fashion to a bypass granuloma tissue on the
anterior aspect of the trachea diagnosis on bronchoscopy on
[**11-29**].  He now is able to ventilate considerably better.
His ventilator was ultimately weaned to a pressure support of
between 10 and 12 with a PEEP of 10, and an FIO2 of 0.4,
pulling in volumes of 300 cc to 400 cc per breath.  His
mental status continued to clear to his baseline; however, he
appeared more depressed than usual, and per Psychiatric
consultation was started on Celexa at 10 mg p.o. q.d. to be
advanced 20 mg p.o. q.d.   His renal function continued to
remain stable with a creatinine of 0.9 to 1.  His edema
resolved impressively with minimal pitting edema below the
knee, 1+ above the knee, and 2+ in the presacral region.  He
was maintained on Lovenox for anticoagulation with regard to
his valves.

MEDICATIONS ON DISCHARGE:   Will be dictated in a second
addendum.

DISCHARGE STATUS:  Will be dictated in a second addendum.

CONDITION AT DISCHARGE:  Will be dictated in a second
addendum.



                          [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7169**]

Dictated By:[**Last Name (NamePattern4) 98138**]

MEDQUIST36

D:  [**2123-11-30**]  17:44
T:  [**2123-11-30**]  15:51
JOB#:  [**Job Number **]

 (cclist)


Admission Date:  [**2123-9-20**]       Discharge Date: [**2123-10-14**]

Date of Birth:   [**2069-5-9**]       Sex:  M

Service:
CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  This is a 54 year old gentleman
with multiple medical problems including coronary artery
disease, congestive heart failure, prosthetic mitral valve
placement.  The patient was admitted with shortness of breath
and pulmonary edema.  The patient was status post mitral
valve replacement and tricuspid valve replacement,
pericardial stripping on [**2123-8-10**].  He had a prolonged
postoperative course complicated by failure to wean from
ventilator with tracheostomy and percutaneous endoscopic
gastrostomy tube placement and Methicillin resistant

The patient was transferred to the rehabilitation center on
[**2123-9-6**].  At that time, his weight was 184 pounds and he was
on 40% trach mask.  The patient has had problems with mild to
moderate pulmonary edema since transfer.  The patient had his
right chest tube discontinued today on the day of admission.
He had worsening shortness of breath afterwards.  He was
noted to be in pulmonary edema on examination and was
transferred to the [**Hospital1 69**] for
evaluation and treatment of his pulmonary edema and possible
transfusion for low hematocrit.

In the Emergency Department, the patient was found to be with
a oxygen saturation in the low 90s on 50% trach mask.  He was
vigorously suctioned.  Afterwards, he was 99% on 40% FIO2.
He also was given Lasix 60 mg times one with good urine
output 500 cc in the first two hours and 750 cc total.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent in [**4-1**].
2.  Congestive heart failure.
3.  Status post mitral valve replacement and tricuspid valve
replacement [**2123-8-10**].
4.  AICD [**4-1**].
5.  History of cerebrovascular accident secondary to coronary
artery disease, residual left finger numbness.
6.  History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical discectomy.
9.  History of nasal treatment.
10. Tracheostomy [**2123-8-25**].
11. Gastrostomy tube placement [**2123-8-25**].
12. Methicillin resistant Staphylococcus aureus pneumonia
diagnosed [**2123-9-2**].
13. Constrictive pericarditis.
14. Iron deficiency anemia.

MEDICATIONS ON ADMISSION:
1.  Amiodarone 400 mg q.d.
2.  Captopril 6.25 mg q.d.
3.  Thyroxine 125 mcg q.d.
4.  Potassium Chloride 10 meq q.d.
5.  Ranitidine 150 mg q.d.
6.  Oxazepam q.h.s.
7.  Coumadin.
8.  Lasix 60 mg q.d.
9.  Lovenox 60 mg subcutaneous b.i.d.

FAMILY HISTORY:  Father died from colon cancer.  No history
of coronary artery disease.

SOCIAL HISTORY:  The patient is married.  He does not smoke
or drink alcohol.  He currently lives in [**Hospital1 **]
Rehabilitation Center.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  In general, the patient is resting
comfortably in bed in no acute distress.  Vital signs
revealed temperature 97.2, blood pressure 104/48, pulse 83,
oxygen saturation 97% on 50% trach mask.  Head, eyes, ears,
nose and throat - The pupils are equal, round, and reactive
to light and accommodation.  Extraocular movements are
intact.  Anicteric sclerae.  Hearing aids in place.  Moist
mucous membranes.  The neck is supple without
lymphadenopathy.  Lungs - coarse sounds throughout, no
wheezes, crackles about half way up bilaterally.
Cardiovascular - jugular venous distention about 10
centimeters, carotids normal with brisk upstrokes, regular
rate and rhythm, normal S1 and S2, with metallic opening
snap.  Abdomen - soft, nontender, nondistended, normoactive
bowel sounds.  Extremities - Positive pitting edema of the
lower extremities to thigh  Positive pitting edema in arm.
Well healed scar on left arm, PICC in the right arm,
dressings to both heels for decubitus ulcers.  Chest - well
healed medicine scar, dressings to both chest tube sites with
serosanguinous drainage.  Rectal - guaiac negative.

LABORATORY DATA:  Hematocrit 23.9, platelets 598,000, white
blood cell count 9.2.  Sodium 141, potassium 5.1, chloride
104, bicarbonate 20, blood urea nitrogen 81, creatinine 1.1,
glucose 90.  Calcium 7.6, magnesium 3.8, phosphorus 4.8,
albumin [**2123-9-8**], 1.7.  Prothrombin time 14.2, partial
thromboplastin time 35.4, INR 1.3.  CK #1 was 50.  Total
bilirubin 0.85, LDH 229, transferrin low 2.02, folate 43.7,
haptoglobin 81, TIBC 45, iron 4.0, reticulocyte count 3.0% on
[**2123-9-17**].  Urinalysis - specific gravity 1.009, positive
blood, [**4-5**] white blood cells, negative bacteria, negative
nitrites. TSH on [**2123-9-2**], was 26.  Free T4 was 0.7.  T3 was
less than 30.

Chest x-ray - right loculated effusion, increased left
effusion.

Electrocardiogram - ventricular paced electrocardiogram,

Transthoracic echocardiogram from [**2123-8-18**], revealed an
ejection fraction of 20 to 25%, severe left ventricular
hypokinesis, decreased right ventricular systolic function,
2+ aortic insufficiency, prosthetic mitral valve and
tricuspid valve, positive ascites, positive left pleural
effusions.

Catheterization [**2123-4-6**], revealed ejection fraction of 35%,
global left ventricular hypokinesis, 2 to 3+ mitral
regurgitation, right coronary artery normal, obtuse marginal
normal, left anterior descending normal, circumflex 90%
stenosis proximally, patch pericardiac calcifications, right
atrium 22/24/19, right ventricle 38/19, left ventricle
108/19, pulmonary capillary wedge pressure 20/20/18, cardiac
output 3.1, cardiac index 1.7.

IMPRESSION:  This is a 54 year old man with multiple medical
problems including coronary artery disease, congestive heart
failure, prosthetic mitral valve and tricuspid valve, who has
been on a trach mask since discharge on [**2123-9-6**].  He has
chronic problems with pulmonary edema.  He presents on
[**2123-9-20**], with increased shortness of breath and pulmonary
edema in the context of having a chest tube pulled that day.

HOSPITAL COURSE:
1.  Cardiovascular - Myocardium - The patient's ejection
fraction postoperative was 20 to 25% with severe left
ventricular hypokinesis.  His outpatient regimen is Captopril
6.25 mg t.i.d., Lasix 60 mg q.d., Amiodarone 400 mg q.d.,
with p.r.n. Lasix.  On admission, he had pulmonary edema and
it was decided to continue to diurese him with a goal of
negative two liters by the next day.

During the first four days of admission, the patient's
Captopril was increased from 6.25 mg to 25 mg t.i.d.  Digoxin
as well as Aldactone was added to his regimen.  It was
attempted to diurese him but he seemed intravascularly dry
with blood urea nitrogen/creatinine ratio of 80.  It was felt
that his fluid was all third spaced.

The patient was placed on Digoxin 0.125 mg q.d., Aldactone 25
mg and Lasix 70 mg p.o. q.d.  It was thought to increase his
Lasix dose and to change his Captopril to Mavik 2 mg.  He was
continued on this regimen of medications until [**2123-9-28**], with
systolic blood pressure of 60 to 80s.  His Mavik was
discontinued secondary to this low blood pressure.  His
Digoxin was also discontinued secondary to increased Digoxin
level.

His blood pressure was thought to be low because he was
intravascularly dry secondary to continual third spacing of
all fluids.  His blood pressure was difficult to maintain
because there was a 20 point systolic blood pressure
difference between his right and left arm, his right being 20
points greater than the left arm, but unable to use right
upper extremity for blood pressure measurements because his
PICC line was in place.

In the setting of his decreased blood pressure, right femoral
arterial line was placed.  He was started on Dopamine.
Central venous pressure line was placed and was unable to go
across the tricuspid valve replacement with a central venous
pressure of 12, cardiac output of 7.1 and SVR of 700.

The etiology of his shock was felt to be vasodilatory, sepsis
versus myxedema versus adrenal suppression and the patient
was started on Neo-Synephrine.  His Neo-Synephrine was
maintained for five days and weaned to off on [**2123-10-3**], with
systolic blood pressure in the 120s.

He was started on Captopril and titrated to 25 mg p.o. t.i.d.
His mean arterial pressures were 60 to 70.  The patient on
[**2123-10-5**], was on Captopril 25 mg t.i.d., Digoxin 0.0625 mg
q.d. with systolic blood pressure in the 120/50 range.

Repeat echocardiogram on [**2123-9-28**], showed an ejection
fraction of less than 25% with severe global left ventricular
hypokinesis.  His blood cultures did not grow anything.  His
Neo-Synephrine was weaned off.  The patient was placed on
Zosyn for his sepsis.  The patient was eventually placed on a
Lasix drip with a fluid goal of negative one liter.  His
Captopril was increased to 37.5 mg t.i.d. on [**2123-10-6**].  His
fluid balance goal continued to be negative 500 to negative
one liter.  He seemed slightly fluid overloaded.  Digoxin was
restarted.  Lasix drip was titrated for adequate urine
output.

On [**2123-10-8**], the patient was thought to be euvolemic.  On
[**2123-10-9**], the patient was thought to be negative fluid
balance which was the goal at that time.  Because of low
blood pressure in the morning following his Captopril dose,
his Captopril dose was decreased to 25 mg t.i.d. on [**2123-10-9**].
On [**2123-10-10**], his Lasix drip was stopped secondary to a bump
in his blood urea nitrogen and creatinine up to 115 and 1.7.
On that same day, his Captopril was changed to Zestril 10 mg
q.d. for better blood pressure control without the episodes
of hypotension.

On [**2123-10-11**], it was felt that the patient was dry and his
goal fluid status was changed to euvolemic to positive over
24 hours.  On [**2123-10-11**], his right femoral arterial line was
taken out and his blood pressure was being able to be
monitored on his right arm despite his PICC line.  On
[**2123-10-12**], the patient was felt to be dry especially since he
was not receiving any tube feeds because of possible
procedure that day.  His urine output was also low so he was
bolused 250 cc of normal saline three times.  This increased
his urine output.

Coronary arteries - The patient's last catheterization was
[**2123-4-16**], showing one vessel coronary artery disease which
was stented.  He was continued on Aspirin throughout his
hospitalization stay.  Stenosis was in his left circumflex at
90% stenosis.  The patient should be considered to begin beta
blocker as an outpatient once he is discharged.

Conduction - The patient has a history of nonsustained
ventricular tachycardia with inducible ventricular
tachycardia on electrophysiology study.  He has an ICD in
place and Amiodarone started in [**2123-4-1**].  On admission, he
was in ventricular paced rhythm and remained this way
throughout his hospitalization stay.

Dual chamber pacer - His Amiodarone was continued at the dose
of 400 mg q.d., paced to 80 beats per minute.  The patient
will need pulmonary function tests at some point as an
outpatient because of the possible side effect of pulmonary
fibrosis with Amiodarone.  He will need to be less
deconditioned for this.  His electrolytes remained fairly
stable throughout his hospital stay and were repleted as
needed.

Valves - The patient has prosthetic mitral valve and
tricuspid valve.  His goal INR is 2.5.  The patient was
subtherapeutic on admission, was given Lovenox on the day of
admission, but was started on Heparin drip while he was in
the hospital until his therapeutic INR was reached.  The
patient's Heparin drip was stopped for several days in the
beginning of [**Month (only) **] because of a large left groin and
thigh hematoma which developed.  It was restarted but then
stopped again briefly because of bright red blood from his
trachea, however, this stabilized and by discharge, he was
back on the Heparin drip for several days.  Please see
hematology section for more details.

2.  Pulmonary - The patient has a history of congestive heart
failure.  He has been on tracheal mask at 40% FIO2.  He
presented with pulmonary edema and left pleural effusion.  It
was decided to diurese him.  Additionally, right chest tube
was removed on [**2123-9-20**], no pneumothorax seen on chest x-ray.
He continued to require frequent suctioning and sputum was
sent for culture.  In addition, the patient's chest x-ray
showed bilateral pulmonary edema and possibly pneumonia. His
white blood cell count began to increase in the first few
days of hospitalization.  Because of his history of
Methicillin resistant Staphylococcus aureus pneumonia, he was
began on Levaquin, Flagyl and Vancomycin.

On [**2123-9-24**], the patient's right pleural effusion was tapped
and it was found to be a transudate.  Left pleural effusion
was still present.  At that point, his sputum culture was
positive for Methicillin resistant staphylococcus aureus and
it was decided to treat that for ten days.  On [**2123-9-24**], he
was saturating well on 40% FIO2.

In the first few days of hospitalization, bronchoscopy was
done showing dried blood, no active bleeding which was
consistent with suction trauma.  It was decided to
bronchoscope him because of bloody mucus that he developed.
Once he was identified with Methicillin resistant
Staphylococcus aureus, his Levaquin and Flagyl were
discontinued.  It was decided to continue his Vancomycin for
a total of 28 day course.

On [**2123-9-28**], in the setting of decreased blood pressure, the
patient requiring increased oxygen requirement and
desaturation into the 80% range on FIO2 100% trach mask, the
patient was ventilated with good oxygenation on FIO2 60% and
PEEP of 10.  He stayed intubated for five days and
transitioned to a trach mask on [**2123-10-2**].

He then maintained good oxygenation with 95% oxygen
saturation on 15 liters of FIO2, 50% trach mask.   Chest
x-ray on [**2123-9-30**], was consistent with bilateral pleural
effusions and right lower lobe pneumonia.  Methicillin
resistant Staphylococcus aureus with question of adult
respiratory distress syndrome.

On [**2123-10-3**], the patient was noted to have a hernia/bulge on
the left chest wall at the chest tube site approximately five
centimeters in size.  CT showed pleural herniation, no lung
tissue.

On [**2123-10-6**], his Zosyn course of seven days for possible
sepsis was finished and it was discontinued.  CT surgery
indicated that the left sided bulge was stable and that there
was nothing to be done for it.  The patient's Vancomycin was
held on [**2123-10-4**], for a high level of 42.3.  His Vancomycin
trough continued to be high and so it was continued to be
held.  His repeat chest x-ray on [**2123-10-6**], showed decreased
bilateral pleural effusions and no change in his right middle
lobe infiltrate.  CT surgery indicated that the left bulge is
a chest wall defect intercostal with no lung present on CT
scan.  There is moderate left sided effusion and they
recommend a thoracentesis but no treatment for the bulge.  It
was decided by the CCU team to hold off on tapping his
pleural effusion.

The patient failed a trial with trach  valve on
[**2123-10-9**], and it was decided to replace his tracheostomy to a
#6 from a #8.  On [**2123-10-11**], the patient's Vancomycin trough
level was 15.9 and it was decided to give him one gram
intravenously times one.  The patient did experience two days
of bright red blood from  his tracheostomy tube and
interventional pulmonology was following him.  They did do a
scope and found some superficial bleeding vessels and were
planning to cauterize it but then the bleeding stopped on its
own and it was decided to hold off on cauterization and
scoping.  The patient failed the trach valve again on
[**2123-10-11**], and the plan was for interventional pulmonology to
scope to look for an obstruction causing this failure with
the valve, however, on [**2123-10-12**], a new tracheostomy was
placed, this time size #4, and on [**2123-10-13**], the  trach
valve was retried with success, having the patient talk
without it popping off.  Therefore, the scope of his trachea
was held off.

On [**2123-10-13**], it was noted that the left chest wall bulge was
increased in size and was firmer.  CT surgery was called to
take a look at it and they decided that there was nothing to
be concerned about, that there was pleural fluid in that
bulge and could be treated conservatively and left alone.

3.  Renal - The patient's blood urea nitrogen and creatinine
on admission appeared to be at his baseline, however, he was
also felt to be intravascularly dry with a high ratio of
blood urea nitrogen/creatinine on [**2123-9-24**], with third
spacing of his fluids so there was an increase in his blood
urea nitrogen and creatinine over the next three to four days
with decreased urine output not responding to Lasix.  On
[**2123-9-28**], his blood urea nitrogen/creatinine peaked at
137/2.2.

He was started on Dopamine which was changed to
Neo-Synephrine with increased urine output of greater than
150 cc/hour for two days.  Urine output started to decrease
so he was transitioned to Lasix boluses which was then
changed to Lasix drip with continued good urine output.

Renal consultation was requested on [**2123-9-28**].  They thought
him to be severely prerenal.  His blood urea
nitrogen/creatinine decreased over three to four days to
71/1.3.  On [**2123-10-5**], he had a slight decrease in urine
output and it was decided to transfuse the patient with two
units of packed red blood cells to help mobilize his fluids.
His creatinine clearance on [**2123-10-2**], was 24 via a 24 hour
collection.

At the beginning of [**Month (only) **], his bicarbonate was noted to
be elevated up to 40 on [**2123-10-6**].  It was decided if it rose
any further, Acetazolamide would be started for better
diuresis, however, it did not go over 40 and actually
decreased to approximately low 30s and Acetazolamide was
never started.

On [**2123-10-7**], the patient's goal net fluid balance was
negative 500 to negative one liter.  His increased
bicarbonate was thought to be secondary to diuretic
treatment/transfusion/contract alkalosis.  His potassium was
kept above 4.0.  On [**2123-10-10**], since the patient was felt to
be dry, his goal fluid balance was changed to
positive/neutral and the Lasix drip was discontinued.

His Lasix drip was also discontinued because of an increase
in his blood urea nitrogen and creatinine.  On [**2123-10-10**], his
blood urea nitrogen and creatinine were 115 and 1.7.  Even
after the Lasix drip was discontinued, the patient's blood
urea nitrogen and creatinine continued to be elevated with
blood urea nitrogen of 100 and creatinine 1.6 on discharge.
On [**2123-10-12**], the patient was given fluid boluses of 250 cc
times three, total of 750 cc for low urine output and a dry
state.

4.  Hematology - The patient was anemic on admission thought
to be iron deficiency anemia, which seemed to be chronic.  He
had continuous serosanguinous drainage from his chest tube
sites.  He was continued on iron and on admission was
transfused two units of packed red blood cells with Lasix.
Anticoagulation wise, he was placed on a Heparin drip.  The
patient's baseline hematocrit at home or in the
rehabilitation center was 27.0 to 29.0.  After receiving the
two units of packed red blood cells, he stayed at 30.0.  He
did have guaiac positive stools, but his lavage was negative.
Esophagogastroduodenoscopy showed gastritis and Barrett's
esophagus but no active bleeding.  On [**2123-9-24**], he was no
longer guaiac positive.

The patient did have a low haptoglobin and hemolysis workup
was done.  Initially his hemolysis laboratories were negative
as was his bronchoscopy negative for active bleeding.  The
patient's hematocrit fluctuated between 26.0 and 30.0 and he
received two units of packed red blood cells on [**2123-9-29**].  On
[**2123-9-28**], in the setting of decreased systolic blood pressure
and increased hypoxia, central arterial access and central
venous access was attempted and after multiple sticks
bilaterally, right femoral artery and right femoral CVL were
obtained, however, the patient received a right femoral
hematoma, small and well circumscribed, and a left large
hematoma, but remained clinically stable.

Since [**2123-9-28**], and [**2123-10-6**], the patient received a total of
six units of packed red blood cells for hematocrit between
24.0 and 30.0.  On [**2123-10-3**], he received two units of packed
red blood cells with increased hematocrit to 27.0 which
decreased to 24.0 two days later.  He was given then two more
units of packed red blood cells.  CT of the abdomen and
pelvis were obtained on [**2123-10-5**], showing left groin hematoma
and right psoas hematoma, 4.0 by 4.0 centimeters.  Throughout
the decreased hematocrit values, the patient was maintained
on Heparin drip for his St. [**Male First Name (un) 923**] artificial valve.  He was on
Coumadin but was switched to Heparin for better control.
Goal partial thromboplastin time was low 50s.

The patient was guaiac negative on [**2123-10-6**].  It was planned
to check his percutaneous endoscopic gastrostomy lavage.
Ultrasound of his groin was negative for pseudoaneurysm and
it was decided on [**2123-10-6**], to recheck his hematocrit at noon
because of decreased from 32.0 to 28.0.  Vascular surgery was
consulted about his right psoas and left groin hematomas.
His noon hematocrit on [**2123-10-6**], was 30.7 so it was decided
not to lavage his percutaneous endoscopic gastrostomy fluid
and he was not transfused.  On [**2123-10-6**], it was decided to
stop his Heparin drip for the decreased hematocrit but then
on [**2123-10-7**], it was decided to restart it at 1000 units per
sliding scale with goal partial thromboplastin time of 50 to
60.  Since his noon hematocrit was 30.7 on [**2123-10-6**], it was
decided to transfuse for less than 27.0 or 28.0.  Direct
Coombs test and haptoglobin, LDH and indirect bilirubin were
checked.

On [**2123-10-8**], the patient was noted to have bright red blood
coming out of his tracheostomy.  His Heparin drip was turned
off.  Pulmonary team was called to assess this.  On [**2123-10-8**],
it was noted that his left groin thigh hematoma was less
indurated.  Vascular surgery team believed that no surgical
or interventional radiology intervention was appropriate at
this time.  The patient's direct Coombs was negative.
Haptoglobin was low and direct bilirubin was normal. LDH was
high.  He was thought to have hemolytic anemia, most likely
due to his artificial valves.

On [**2123-10-8**], his Heparin drip was restarted at 7:00 p.m. with
the approval of the interventional pulmonology team.  On
[**2123-10-10**], the patient was transfused one unit of blood for
hematocrit of 26.9. His hematocrit did not bump very much
with this and he went up to 27.6.  The patient's right groin
A line was pulled on [**2123-10-10**], and he developed a small right
groin hematoma which remained stable.  It was decided to
recheck his hematocrit at noon on [**2123-10-11**], and transfuse if
less than 27.0, however, this was not needed.  His
tracheostomy stopped bleeding after a couple days.  The
patient's hematocrit did bump to 31.2.  His Heparin drip was
restarted on [**2123-10-8**].

On [**2123-10-13**], the patient's hematocrit was 27.7 and it was
decided to transfuse him one unit of blood, not so much for
the thought of him actively bleeding anywhere, but more for
intravascular volume.  The patient was guaiac negative on
discharge.  It was decided to give him a dose of Lovenox 60
mg on the day of discharge and to stop the Heparin drip three
hours later.  Coumadin was given the afternoon of discharge
as well 5 mg with a goal INR of 2.5 to 3.5 for valvular
protection.

5.  Infectious disease - The patient was afebrile on
admission with copious secretions.  Per nursing reports, this
was a problem for some time, three to five days prior to
admission.  Culture was sent.  The patient completed
Vancomycin for Methicillin resistant Staphylococcus aureus
pneumonia on [**2123-9-2**].  He was thought to have pneumonia on
admission.  Sputum culture was positive for Methicillin
resistant Staphylococcus aureus.  The patient was started on
Vancomycin for a total of 28 days.  For Methicillin resistant
Staphylococcus aureus pneumonia, Vancomycin was being dosed
p.r.n. and levels were followed.  He was redosed for
Vancomycin level of less than or equal to 15.0.  On [**2123-9-29**],
he was noted to have rigors and increased temperature from
his baseline hypothermic of 98 to 99.  In the setting of an
increased cardiac output and decreased SVR to the 200 to
600s, he was felt to have sepsis and he was covered with
Zosyn for seven days to cover pseudomonas.  Repeat urine and
sputum cultures were negative.  Blood cultures continued to
be negative.

On [**2123-10-5**], the patient was afebrile with a white blood cell
count of 14.0.  White blood cell count continued to decrease
and he continued to remain afebrile until discharge.  On
[**2123-10-11**], the patient was given one gram intravenously times
one of Vancomycin after it had been held for several days for
high trough level.  On [**2123-10-11**], it was 15.9.  On [**2123-10-13**],
his Vancomycin trough level was 22.1.

6.  Endocrine - The patient has diagnosis of hypothyroidism.
His TSH was high at 87 and free T4 low at 0.8.  It was
decided to increase his Synthroid to .175 mcg.  By suggestion
of the endocrine team which was consulted, it was thought to
be secondary to Amiodarone although he was not thought to be
in myxedema coma.  His thyroid function tests were rechecked
on [**2123-10-7**].  In addition, endocrine consultation was
obtained for adrenal crisis on [**2123-9-28**], in the setting of
hypotension, decreased urine output and respiratory failure.
He was given a stress dose of steroids and drew random
cortisol level which was 23.  It was felt an adequate
response per endocrine and no more steroids were given.

On [**2123-10-7**], repeat thyroid function tests were done.
Because of continued increased level of TSH and decreased
level of free T4, the endocrine team recommended increasing
his Synthroid dose to 0.2 mg q.d. and asked for his thyroid
function tests to be rechecked on [**2123-10-16**].

7.  Gastrointestinal - The patient had a percutaneous
endoscopic gastrostomy tube in on admission.  He was
continued on tube feeds and Zantac for prophylaxis.  The
patient was guaiac positive on admission and was evaluated
for gastrointestinal bleed.  Esophagogastroduodenoscopy was
negative.  The patient was on Prevacid through his tube
feeds.  His stools then became guaiac negative.  Video
swallowing study from previous hospital admission showed
positive aspiration.

8.  FEN - The patient was in fluid overload on admission.
Goal was negative two liters.  Electrolytes were within
normal limits on admission.  Nutrition was poor with low
albumin of 1.7 and he was started on tube feeds.  He was also
thought to be intravascularly dry with third spacing.
Nutrition was consulted and he was placed on Impact with
fiber tube feeds.  The patient was not placed on intravenous
fluids given his total body fluid overload and third spacing.
In the setting of diuresis, the patient was repleted his
magnesium and potassium.

On [**2123-9-30**], he was noted to have undigested tube feeds in
the setting of Fentanyl drip for sedation.  This resolved
stopping the Fentanyl.  His albumin continued to be low at
2.0 to 2.5.  His fluid balance goal then changed negative 500
to negative one liter.  On [**2123-10-11**], his goal fluid balance
was then changed to positive/euvolemic.  He was thought to be
dry with low urine output.  On [**2123-10-13**], the patient was
transfused one unit of packed red blood cells for
intravascular volume repletion.

9.  Neuropsychiatry - During his hypotensive episodes, the
patient was placed on Fentanyl drip for sedation but was
weaned off the next day.  The patient does have a history of
stroke in the past prior to admission with left finger
numbness as a residual effect. This question was raised on
rounds about the patient's mood, anhedonia signs.  Discussed
with the patient's wife.  She felt he was not depressed but
more frustrated with not being able to eat and his having to
have a tracheostomy in.  In discussion with his wife, it was
decided to hold his antidepressants at this time.

On [**2123-10-13**], when his ************* valve was successful and
the patient was finally able to speak, he did seem to have a
more elevated mood due to his feeling happy about being able
to speak.

10. Prophylaxis - The patient was turned regularly.  He was
on the Heparin drip on and off.  He was on Prevacid for
gastrointestinal prophylaxis and multipedis splints.

11. Lines - The patient had a right PICC placed, right
femoral artery, tracheostomy, Foley and rectal stool bag
during this admission.  Because of multiple attempts to place
an arterial line, he had a large left groin hematoma.  On CT
scan of the abdomen and pelvis, he was clinically stable.
Ultrasound showed no pseudoaneurysm and he was followed and
the induration due to the hematoma did seem to decrease in
size as did the tenderness.  He remained neurologically
intact with intact pulses in his feet.  The rectal bag was
discontinued.

Physical therapy who evaluated the patient during his
hospitalization stay could not mobilize him very much because
of his right groin femoral arterial line, however, this was
maintained for longer than would have been ideal because of
his intermittent decreases in blood pressure.  On [**2123-10-10**],
his right groin A line was removed and he was able to sit up
with the help of physical therapy and do more exercises with
them.  He did develop a small hematoma in the area but his
remained stable.

His right PICC line remained in and will remain in because of
his continued Vancomycin treatment but the nurses were able
to measure blood pressure on his right arm.

12. Code Status - Full.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  Back to [**Hospital1 49166**].

DISCHARGE MEDICATIONS:
1.  Albuterol/Atrovent nebulizers q4hours p.r.n.
2.  Amiodarone 400 mg q.d.
3.  Miconazole cream 2% apply to folds b.i.d.
4.  Aspirin 325 mg p.o. q.d.
5.  Aldactone 25 mg p.o. q.d., hold for systolic blood
pressure less than 85.
6.  Digoxin 0.0625 mg p.o. q.d., hold for pulse less than 50.
7.  Prevacid 30 cc via percutaneous endoscopic gastrostomy
tube q.d.
8.  PICC flush 200 units Heparin and 60 cc normal saline
b.i.d.
9.  Impact with fiber at 40 cc/hour and increase as tolerated
to goal of 80 cc/hour.  Check residual q4hours and hold for
greater than 100 cc
10. Iron Sulfate 325 mg p.o. percutaneous endoscopic
gastrostomy tube t.i.d.
11. Synthroid 0.2 mg p.o. percutaneous endoscopic gastrostomy
tube q.d.
12. Zestril 10 mg p.o. percutaneous endoscopic gastrostomy
tube Q.d.
13. Tylenol 650 mg p.o. percutaneous endoscopic gastrostomy
tube q4-6hours p.r.n.
14. Serax 15 to 30 mg p.o. q.h.s. p.r.n.
15. Ativan 0.5 to 1 mg intravenously q4-6hours p.r.n.
16. Lovenox 60 mg subcutaneous b.i.d.
17. Coumadin 5 mg p.o. q.h.s.

DISCHARGE INSTRUCTIONS:
1.  The patient to receive physical therapy two to three
times a week.

2.  The patient to be NPO and have a video swallow study on
the day after arriving at the rehabilitation center, possibly
[**2123-10-14**], or [**2123-10-15**], to compare with the previous one and
to evaluate him for aspiration before restarting p.o. intake.

3.  Please check every day prothrombin time and INR and stop
the Lovenox when the INR is therapeutic between 2.5 and 3.5
for two days.

4.  Please check every day Vancomycin trough level. If less
than or equal to 15.0, may give one gram intravenous times
one, but stop checking or giving Vancomycin on [**2123-10-20**].
That will be the end of his course.

5.  The patient has a left chest wall bulge.  It has been
evaluated by CT surgery team and is not concerning and should
be left alone.

6.  Please check TSH, free T4 and T3 on [**2123-10-16**], and inform
the patient's doctor with possible change in his Synthroid.

7.  Please check blood urea nitrogen and creatinine every 48
hours.

8.  Please check electrolytes, Chem7, calcium, magnesium, and
phosphorus every week.

9.  Please check Digoxin level in one week.

10. The patient does receive percutaneous endoscopic
gastrostomy tube feedings.

11. Please have occupational therapy and speech therapy
evaluate the patient.

12. Please have the patient's primary care physician see the
patient within five days after discharge.

DISCHARGE DIAGNOSES:
1.  Congestive heart failure.
2.  Right middle lobe Methicillin resistant Staphylococcus
aureus pneumonia.
3   Left groin thigh resolving hematoma.
4.  Tracheostomy in place with a ************* valve.
5.  Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent [**4-1**].
6.  Status post mitral valve replacement and tricuspid valve
replacement, St. [**Male First Name (un) 923**], [**2123-4-10**].
7.  AICD [**4-1**].
8.  History of cerebrovascular accident secondary to coronary
artery disease with residual left finger numbness.
9.  History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
10. Hypercholesterolemia.
11. History of cervical discectomy.
12. History of nasal treatment.
13. Percutaneous endoscopic gastrostomy tube placement
[**2123-8-25**].
14. History of constrictive pericarditis.
15. Combination of iron deficiency and hemolytic anemia.


                          DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12-270



Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36

D:  [**2123-10-13**]  16:40
T:  [**2123-10-13**]  17:54
JOB#:  [**Job Number 98134**]

cc:[**Hospital1 98135**]
        [**Location (un) **]
              , [**Numeric Identifier 98136**]

        Fax [**Telephone/Fax (1) 98137**]
{"Congestive heart failure, unspecified,Unspecified pleural effusion,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Unspecified septicemia,Paroxysmal ventricular tachycardia,Aortic valve disorders,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Heart valve replaced by other means"}


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: This is a 54 year old gentleman
with multiple medical problems including coronary artery
disease, congestive heart failure, prosthetic mitral valve
placement.  The patient was admitted with shortness of breath
and pulmonary edema.  The patient was status post mitral
valve replacement and tricuspid valve replacement,
pericardial stripping on [**2123-8-10**].  He had a prolonged
postoperative course complicated by failure to wean from
ventilator with tracheostomy and percutaneous endoscopic
gastrostomy tube placement and Methicillin resistant

MEDICAL HISTORY: 1.  Coronary artery disease, status post inferior myocardial
infarction in [**2115**], complicated by left ventricular thrombus,
status post left circumflex stent in [**4-1**].
2.  Congestive heart failure.
3.  Status post mitral valve replacement and tricuspid valve
replacement [**2123-8-10**].
4.  AICD [**4-1**].
5.  History of cerebrovascular accident secondary to coronary
artery disease, residual left finger numbness.
6.  History of Hodgkin's lymphoma at the age of 27, status
post mantel radiation and splenectomy.
7.  Hypercholesterolemia.
8.  History of cervical discectomy.
9.  History of nasal treatment.
10. Tracheostomy [**2123-8-25**].
11. Gastrostomy tube placement [**2123-8-25**].
12. Methicillin resistant Staphylococcus aureus pneumonia
diagnosed [**2123-9-2**].
13. Constrictive pericarditis.
14. Iron deficiency anemia.

MEDICATION ON ADMISSION: 1.  Amiodarone 400 mg q.d.
2.  Captopril 6.25 mg q.d.
3.  Thyroxine 125 mcg q.d.
4.  Potassium Chloride 10 meq q.d.
5.  Ranitidine 150 mg q.d.
6.  Oxazepam q.h.s.
7.  Coumadin.
8.  Lasix 60 mg q.d.
9.  Lovenox 60 mg subcutaneous b.i.d.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died from colon cancer.  No history
of coronary artery disease.

SOCIAL HISTORY: The patient is married.  He does not smoke
or drink alcohol.  He currently lives in [**Hospital1 **]
Rehabilitation Center. 

### Response:
{"Congestive heart failure, unspecified,Unspecified pleural effusion,Methicillin susceptible pneumonia due to Staphylococcus aureus,Hematoma complicating a procedure,Unspecified septicemia,Paroxysmal ventricular tachycardia,Aortic valve disorders,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Heart valve replaced by other means"}
