CHIEF COMPLAINT: Fall and SOB

PRESENT ILLNESS: 89yo CM with PMHx significant for CAD s/p incomplete atherectomy
and PCA ([**1-27**]), and recent echo ([**7-27**]) demonstrating CHF (EF:
25-30%), moderate AS (valve area 1.0), mild->mod AR, mod MR, mod
TR, and mild pulm artery systolic HTN as [**Doctor Last Name **] as DM2, and CKI
(baseline Cr ?2-2.7) who was admitted to the ICU for managment
of altered mental status in the setting of hypervolemic
hyponatremia.
.
Prior to his admission the patient had been gaining weight (from
172 lbs to 180 lbs) and had B/L effusions on CXR, which prompted
his PCP to increased his Toresimide on [**7-12**] from 10 mg to 20 mg
in the AM and 5 mg to 10 mg in the PM. Over the next week his
weight remained stable at 184. And per a prior note his wife
reports that the patient had experienced a decrease in urine
output, but no CP, SOB, PND, orthopnea, or abdominal pain.
.
On day of admission the patient was leaning over to put on his
slippers and fell over. His wife found him alert and attempting
to get up, then called the EMS. In the ED he was awake and
responsive and his initial vitals were 97.4, 82, 137/89, 16, 91%
on 3L NC, but throughout the next couple of hours he became
unresponsive and was found to be hyponatremic to 118. Head CT
was negative. He was guaic-negative.
.
In the MICU it was determined that the patient's hyponatremia
was hypervolemic hyponatremia consistent with his history of
heart failure and chronic kidney injury. He was placed on a
lasix drip and diuresed about 6L, taking into consideration the
need to not decrease his preload in the setting of AS in order
to maintain his CO. Renal was consulted for his elevated Cr,
which occurred likely secondary to poor forward flow state and
suggested an SPEP/UPEP, which was negative for Bence [**Doctor Last Name **]
protein. His lasix drip was d/c and he continued to
auto-diurese. His Toresmide was restarted and a Heart Failure
consult was requested.

MEDICAL HISTORY: Diabetes
Dyslipidemia
CAD s/p PCA in [**1-/2182**]
CHF EF 25-30% ([**7-27**])
Moderate Aortic Stenosis
Mild->Moderate AR
Moderate MR
[**First Name (Titles) **] [**Last Name (Titles) 71133**]
Anemia
CKD (baseline creatinine difficult to assess 2-2.7)
Gout
Recent GI bleed thought [**2-19**] [**Month/Day (2) 4532**], no scope
H. pylori positive [**7-18**] (was being treated prior to hospital)

MEDICATION ON ADMISSION: Atorvastatin 80 mg Tablet DAILY
Glipizide 10 mg Tablet DAILY
Metoprolol Tartrate 12.5 mg Tablet [**Hospital1 **]
NitroQuick 0.4 mg Tablet, Sublingual prn chest pain (not used)
Pantoprazole 40 mg Tablet [**Hospital1 **]
Torsemide 20 mg Tablet in am, 10 in pm
Acetaminophen 500 mg
Aspirin 81 mg
Ferrous Sulfate 325 mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Arousable to voice, Oriented x2
HEENT: MMD
Neck: supple, JVP elevated
Lungs: +rhales b/l
CV: +systolic murmur. S1+, S2+
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +foley
Ext: +edema to thigh b/l.

FAMILY HISTORY: No family history of breast, colon, or prostate cancer. Brother
had heart disease. Children in good health.

SOCIAL HISTORY: The patient was born in [**Country 4754**]. He lives in [**Location 1268**] with
his wife, with whom he has two daughters and a son. [**Name (NI) **] denies
any history of tobacco or drug use. He drinks alcohol in small
amounts, occasionally (on the weekend).
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage IV (severe),Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Helicobacter pylori [H. pylori],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Prickly heat,Contact dermatitis and other eczema, unspecified cause,Anemia, unspecified,Photokeratitis
Ac on chr syst hrt fail,Acute kidney failure NOS,Hyposmolality,Urin tract infection NOS,Delirium d/t other cond,Chr kidney dis stage IV,Crnry athrscl natve vssl,Aortic valve disorder,DMII wo cmp nt st uncntr,Helicobacter pylori,Hy kid NOS w cr kid I-IV,Gout NOS,Prickly heat,Dermatitis NOS,Anemia NOS,Photokeratitis
Admission Date:  [**2182-7-28**]              Discharge Date:   [**2182-8-12**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Fall and SOB

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
89yo CM with PMHx significant for CAD s/p incomplete atherectomy
and PCA ([**1-27**]), and recent echo ([**7-27**]) demonstrating CHF (EF:
25-30%), moderate AS (valve area 1.0), mild->mod AR, mod MR, mod
TR, and mild pulm artery systolic HTN as [**Doctor Last Name **] as DM2, and CKI
(baseline Cr ?2-2.7) who was admitted to the ICU for managment
of altered mental status in the setting of hypervolemic
hyponatremia.
.
Prior to his admission the patient had been gaining weight (from
172 lbs to 180 lbs) and had B/L effusions on CXR, which prompted
his PCP to increased his Toresimide on [**7-12**] from 10 mg to 20 mg
in the AM and 5 mg to 10 mg in the PM. Over the next week his
weight remained stable at 184. And per a prior note his wife
reports that the patient had experienced a decrease in urine
output, but no CP, SOB, PND, orthopnea, or abdominal pain.
.
On day of admission the patient was leaning over to put on his
slippers and fell over. His wife found him alert and attempting
to get up, then called the EMS. In the ED he was awake and
responsive and his initial vitals were 97.4, 82, 137/89, 16, 91%
on 3L NC, but throughout the next couple of hours he became
unresponsive and was found to be hyponatremic to 118. Head CT
was negative. He was guaic-negative.
.
In the MICU it was determined that the patient's hyponatremia
was hypervolemic hyponatremia consistent with his history of
heart failure and chronic kidney injury. He was placed on a
lasix drip and diuresed about 6L, taking into consideration the
need to not decrease his preload in the setting of AS in order
to maintain his CO. Renal was consulted for his elevated Cr,
which occurred likely secondary to poor forward flow state and
suggested an SPEP/UPEP, which was negative for Bence [**Doctor Last Name **]
protein. His lasix drip was d/c and he continued to
auto-diurese. His Toresmide was restarted and a Heart Failure
consult was requested.


Past Medical History:
Diabetes
Dyslipidemia
CAD s/p PCA in [**1-/2182**]
CHF EF 25-30% ([**7-27**])
Moderate Aortic Stenosis
Mild->Moderate AR
Moderate MR
[**First Name (Titles) **] [**Last Name (Titles) 71133**]
Anemia
CKD (baseline creatinine difficult to assess 2-2.7)
Gout
Recent GI bleed thought [**2-19**] [**Month/Day (2) 4532**], no scope
H. pylori positive [**7-18**] (was being treated prior to hospital)

Social History:
The patient was born in [**Country 4754**]. He lives in [**Location 1268**] with
his wife, with whom he has two daughters and a son. [**Name (NI) **] denies
any history of tobacco or drug use. He drinks alcohol in small
amounts, occasionally (on the weekend).

Family History:
No family history of breast, colon, or prostate cancer. Brother
had heart disease. Children in good health.

Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Arousable to voice, Oriented x2
HEENT: MMD
Neck: supple, JVP elevated
Lungs: +rhales b/l
CV: +systolic murmur. S1+, S2+
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +foley
Ext: +edema to thigh b/l.

DISCHARGE PHYSICAL EXAM:
Vitals: T 96.8 / 146/84 (123-146/67-79) / 78 (74-88) / 20 / 98%
on 2L
Exam:
Gen: sick appearing elderly male lying in bed with nasal cannula

Lungs: CTAB in upper fields, decreased airmovement in lower
lungs (less movement in R than L)
Cardiac: RRR, 2/6 systolic ejection murmur loudest over aortic
valve, [**3-23**] diastolic murmur greatest at LLSB, S1 and S2 faint,
S3, S4
Abd: Soft, NT, ND, Bowel sounds normoactive, no rashes on
stomach
LE: 2+ pulses at DP and PT, [**1-19**]+ edema up to mid shin,
petichial/maculopapular confluent rash over bilat LE from below
knees to ankles, feet have small amount of purple on toes. R
thigh cath site shows no bleeding, erythema, or hematoma.
UE: peripheral IV in place, radial pulse 2+, no rash on
extermities
Neuro: alert, oriented x 1


Pertinent Results:
ADMISSION Labs:
CBC: WBC-6.4 RBC-4.03* Hgb-13.1* Hct-37.2* MCV-92 MCH-32.4*
MCHC-35.1* RDW-14.8 Plt Ct-230 Neuts-79.7* Lymphs-11.7*
Monos-7.2 Eos-1.0 Baso-0.4
Coags: PT-15.1* PTT-32.6 INR(PT)-1.3*
Chem: Glucose-108* UreaN-74* Creat-2.7* Na-118* K-5.5* Cl-79*
HCO3-28 AnGap-17 ALT-49* AST-70* LD(LDH)-330* CK(CPK)-641*
AlkPhos-112 TotBili-0.9
Calcium-8.0* Phos-4.9* Mg-2.2 Osmolal-270*
Cardiac Markers:
CK(CPK)-561* CK(CPK)-456* CK-MB-8 proBNP-[**Numeric Identifier 104624**]* cTropnT-0.04*
CK-MB-8 cTropnT-0.04* CK-MB-7 cTropnT-0.03*
.
.
DISCHARGE LABS:
Glucose UreaN Creat  Na   K   Cl  HCO3 AnGap
126*     64*   2.2*  142 4.3  101  37
.
Hct 33.5
.
==========================================
IMAGING Studies:
.
Head CT ([**7-28**]): IMPRESSION: No acute intracranial process.
CXR ([**7-28**]):
IMPRESSION: Increased size of right pleural effusion, now
moderate, with persistent small left pleural effusion.
Subsegmental atelectasis in the right lung base, as well as mild
atelectasis in the left lung base.
.
ECHO ([**7-29**]):
Conclusions: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
to severe global left ventricular hypokinesis (LVEF = 25-30 %).
The estimated cardiac index is borderline low (2.0-2.5L/min/m2).
No masses or thrombi are seen in the left ventricle. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.0 cm2). Mild to moderate ([**1-19**]+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.

Compared with the prior study (images reviewed) of [**2182-4-10**],
biventricular systolic function is more depressed suggesting a
diffuse process. The severity of aortic regurgitation and mitral
regurgitation are increased. The aortic valve gradient is lower,
but is likely due to reduced stroke volume.
.
Cardiac Cath ([**8-6**]):
COMMENTS:
1. Selective coronary angiography of this left dominant system
was
limited to the left-sided circulation. The LMCA had mild
disease. The
LAD was heavily calcified and had serial diffuse 90% stenoses in
the
proximal, mid, and distal portions of the vessel. Angiography of
the
left circumflex demonstrated a 40% proximal stenosis and a 70%
stenosis
at the ostium of the OM1. There was collateral flow from the LAD
to the
distal circumflex system.
2. Resting hemodynamics revealed elevated left and right heart
filling
pressures with a mean PCW of 35 mmHg and RVEDP of 11 mmHg. There
was
moderate to severe pulmonary arterial systolic and diastolic
hypertension with a PASP of 67 mmHg and PADP of 30 mmHg. There
was
moderate systemic arterial hypertension with SBP 152 mmHg. The
cardiac
index was preserved (3.5 l/min/m2).
3. Successful PTCA and stenting of distal LAD with 2.5x18 mini
Vision
bare metal stent.
4. Successful PTCA and stenting of mid LAD with 2.5x18mm mini
Vision
bare metal stent post dilated to 3.0mm.
5. Successful PTCA and stenting of proximal LAD with 3.0x18mm
Vision
bare metal stent post dilated to 3.0mm.
6. Successful closure of right femoral arteriotomy with 6F
angioseal.

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated right and left heart filling pressures
3. Moderate Systemic arterial systolic hypertension
4. Moderate to severe pulmonary arterial systolic and diastolic
hypertension
5. Normal cardiac index
6. Successful PCI of distal LAD with BMS.
7. Successful PCI of mid LAD with BMS.
8. Successful PCI of proximal LAD with BMS.
9. Successful closure of right femoral arteriotomy with 6F
angioseal.
.
ECHO ([**8-7**]):
The left atrium is elongated. The right atrium is dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is severe global left ventricular hypokinesis (LVEF = 25-30 %).
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-19**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2182-7-29**],
the severity of valvular regurgitation is slighlty less. The
other findings are similar.
.
CXR ([**8-10**]):
IMPRESSION: Slight improvement in CHF with persistent bilateral
pleural
effusions.
.
MICROBIOLOGY:
Urine Cx ([**8-3**]):
   URINE CULTURE (Final [**2182-8-3**]):
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
URINE CULTURE (Final [**2182-8-8**]):    <10,000 organisms/ml.
.
ABG ([**8-4**]): 91 63*1 7.39 40* 9
.
Discharge Labs:
Hct-33.5*
Chem: Glucose-126* UreaN-64* Creat-2.2* Na-142 K-4.3 Cl-101
HCO3-37* AnGap-8 Calcium-7.8* Phos-3.2 Mg-1.8

Brief Hospital Course:
# MS change:
Patient's mental status change was likely secondary to
hyponatremia and improved to baseline upon correction of serum
sodium concentration. Head CT showed no evidence of acute
intracranial process. Pt remained A&O x 1 (oriented to self, but
not place and time) upon discharge fromthe ICU. Pt able to carry
on conversations with health care team and seemed aware of
things around him.
.
#Hyponatremia:
The patient's hyponatremia of 118 at presentation was likely
secondary to a hypervolemic state from an acute worsening of
chronic CHF. His serum sodium improved with diuresis and free
water restriction to 1.5L/day. By time of discharge he serum
sodium was a normal value.
.
#Acute on Chronic CHF:
Patient presented with acute decompensation of known systolic
heart failure. This was thought related to known coroanry artery
disease. He initially received aggressive diuresis and was taken
to the cath lab [**2182-8-6**] where he had 3 stents placed in LAD
which was 90% stenosed. He continued to be diuresed with 40mg IV
lasix [**Hospital1 **] until we felt he was euvolemic. He was then restarted
on home dose of torsemide. Pt has bilateral pleural effusions
which have shown interval resolution with diuresis. He remains
on 2L O2 w/ sats in mid 90's. We anticipate that as he mobilizes
effusions he will not need continuous O2. LE remains [**1-19**]+ but
improving with elevation and compression stocking.
.
#Acute on Chronic Kidney Injury:
Mild elevation of Cr from baseline 2.2 to 2.6 felt to be
secondary to heart failure exacerbation. Improved w/ diuresis
and pt returning to euvolemia. Currently Cr around 2.2.
.
#Urinary Tract Infection:
Urine growing proteus. Treated with 10 days of cipro which was
completed [**2182-8-10**].
.
#Aortic Stenosis: Moderate AS with valve area 1.0-1.2cm2 on ECHO
[**2182-8-7**].
We remained cogniscent of the patient's vavular disease
throughout our managment of his volume overload; we were careful
to not over-diurese the patient in order to keep his preload
appropriate to maintain adequate cardiac output.
.
#CAD: Worsening LV function felt to be related to progressive
CAD. No CP on this admission, mild CE elevation. Cardiac cath
was performed on [**8-6**] as mentioned above with 3 stents placed in
his highly diseased LAD. Pt did well after cath with overall
improvement in his heart failure. Pt should continue [**Month/Year (2) **]
daily espec given new drug elution stents. Metoprolol increased
to 25mg [**Hospital1 **]. His lisinopril decreased to 2.5mg daily. He remains
on ASA 325 and atorvastatin 80mg daily.

#B/L pleural effusions R>L:
Likely secondary to decompensated heart failure. Pt spent most
of post-ICU course on 2L NC. He would sat between 88-92% on RA
when at rest, but any exertion would drop his sats 80% if on RA.
At time of discharge pt was still requiring 2L oxygen to
maintain adequate sats with any exertion.  We anticipate these
will continue to resolve and pt will be able to weaned off O2.

# Fall:
Fall prior to admission was likely mechanical with possible
contribution of hyponatremia leading to confusion leading to
fall. A CT Head in ED revealed no trauma or ICH. We consulted
Physical Therapy to assess the patient's gait and provide
rehabilitative inpatient services. The patient will be
discharged to a rehab center for rehabilitation.
.
# DM:
We held the patient's glipizide and began insulin with sliding
scale adjustment and regular accuchecks. His blood sugar levels
were reasonably controlled although the sliding scale was kept
conservate due to patient's age and general poor health.
Glipizide should be restarted at time of discharge.
.
# Rash:
Pt was found to have two different rashes, one on his bilateral
lower extermities from the ankles to the knees and the other
over his back and buttocks. He was seen by dermatology who felt
eruption on his back is most consistent with miliaria secondary
to blockage of the eccrine ducts in an occlusive environment. Pt
should wear loose fitting cotton clothing to promote drying.
Rash on legs felt to be contact dermatitis related to
pneumoboots. Moisturizing cream applied to LE. Pt was also noted
to have a a nodule on his face concerning for a nodular basal
cell carcinoma and likely actinic keratoses on the arms. Please
have the patient follow up with his private dermatologist Dr
[**Last Name (STitle) **] on discharge according to dermatology recommendations.

.
# H. Pylori:
Pt had been found to be H. pylori positive on [**7-15**] by EIA. His
treatment for this was discontinued during his 3 week
hospitalization, but it should be restarted as an outpatient. Pt
was prescribed an alternative regimen [**2-19**] to needing to be off
PPI while on [**Month/Day (2) 4532**] and issues with clarithromycin and other
current drugs. Will send out on renally dosed Tetracycline 500mg
PO TID, Metronidazole 500mg PO TID, Bismuth 2 tabs QID, and
renally dose Ranitidine 150mg daily.

Medications on Admission:
Atorvastatin 80 mg Tablet DAILY
Glipizide 10 mg Tablet DAILY
Metoprolol Tartrate 12.5 mg Tablet [**Hospital1 **]
NitroQuick 0.4 mg Tablet, Sublingual prn chest pain (not used)
Pantoprazole 40 mg Tablet [**Hospital1 **]
Torsemide 20 mg Tablet in am, 10 in pm
Acetaminophen 500 mg
Aspirin 81 mg
Ferrous Sulfate 325 mg

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.

2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every [**6-25**]
hours as needed for pain.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Torsemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
8. Torsemide 20 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Bismuth Subsalicylate 262 mg Tablet Sig: Two (2) Tablet PO
four times a day for 14 days.
Disp:*112 Tablet(s)* Refills:*0*
10. Tetracycline 500 mg Capsule Sig: One (1) Capsule PO three
times a day for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 14 days.
Disp:*42 Tablet(s)* Refills:*0*
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 14 days.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
hyponatremia, acute exacerbation of chronic congestive heart
failure, coronary artery disease, aortic stenosis, chronic
kidney disease


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Last Name (Titles) 104625**],

You were recently admitted to the hospital for confusion that
occurred because the sodium in your blood got too low because of
your heart failure and kidney disease. We were able to use
medications to remove your excess fluid and you showed
improvement. You were taken to the cardiac catheterization lab
and found to have multiple blockages in one of your heart
arteries - 3 stents were placed in this artery to improve your
blood flow. Additionally, you were treated with an antibiotic
for 10 days for a urinary infection you developed during your
hospitalization. With these treatments your condition improved
although you are still requiring supplementary oxygen to
maintain your oxygenation while you are moving around.
.
The following changes were made to your medications:
-Started [**Last Name (Titles) **] 75mg by mouth once each day
-Lisinopril decreased from 10mg by mouth daily to 2.5mg daily
-Pantoprazole stopped -> will start Raniditine 150mg by mouth
once each day in its place as now on [**Last Name (Titles) **]
-Metoprolol increased to 25mg twice a day
-New Medication Tetracycline 500mg by mouth three times each day
for 14 days
-New Medication Metronidazole 500mg by mouth three times each
day for 14 days
-Bismuth subsalucylate 2 tablets four times each day for 14
days.
.
Please follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 131**] and Cardiologist Dr.
[**First Name (STitle) 437**] as listed below.
.
Please make sure to take your [**First Name (STitle) 4532**] every day. If you fail to
take this medication the stents in your heart can become
blocked.
.
Please make sure to follow a diet low in salt and do not drink
more than 1.5 L of fluid each day. Make sure to weigh yourself
every morning, and call the doctor if your weight goes up more
than 3 lbs.

Followup Instructions:
**Additionally, he does have a nodule on his face concerning for
a
nodular basal cell carcinoma and likely actinic keratoses on the
arms. Please have the patient follow up with his private
dermatologist Dr [**Last Name (STitle) **] on discharge

Department: CARDIAC SERVICES
When: MONDAY [**2182-8-19**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Specialty: Congestive Heart Failure
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**First Name11 (Name Pattern1) 132**] [**Last Name (NamePattern4) **],MD
Department: Internal Medicine
When: Thursday [**8-29**] at 10:30am
Location: [**Hospital1 **] HEALTHCARE - [**Hospital **] MEDICAL
GROUP
Address: [**Street Address(2) 2687**],8TH FL, [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 133**]
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage IV (severe),Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Helicobacter pylori [H. pylori],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Prickly heat,Contact dermatitis and other eczema, unspecified cause,Anemia, unspecified,Photokeratitis'}


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: Fall and SOB

PRESENT ILLNESS: 89yo CM with PMHx significant for CAD s/p incomplete atherectomy
and PCA ([**1-27**]), and recent echo ([**7-27**]) demonstrating CHF (EF:
25-30%), moderate AS (valve area 1.0), mild->mod AR, mod MR, mod
TR, and mild pulm artery systolic HTN as [**Doctor Last Name **] as DM2, and CKI
(baseline Cr ?2-2.7) who was admitted to the ICU for managment
of altered mental status in the setting of hypervolemic
hyponatremia.
.
Prior to his admission the patient had been gaining weight (from
172 lbs to 180 lbs) and had B/L effusions on CXR, which prompted
his PCP to increased his Toresimide on [**7-12**] from 10 mg to 20 mg
in the AM and 5 mg to 10 mg in the PM. Over the next week his
weight remained stable at 184. And per a prior note his wife
reports that the patient had experienced a decrease in urine
output, but no CP, SOB, PND, orthopnea, or abdominal pain.
.
On day of admission the patient was leaning over to put on his
slippers and fell over. His wife found him alert and attempting
to get up, then called the EMS. In the ED he was awake and
responsive and his initial vitals were 97.4, 82, 137/89, 16, 91%
on 3L NC, but throughout the next couple of hours he became
unresponsive and was found to be hyponatremic to 118. Head CT
was negative. He was guaic-negative.
.
In the MICU it was determined that the patient's hyponatremia
was hypervolemic hyponatremia consistent with his history of
heart failure and chronic kidney injury. He was placed on a
lasix drip and diuresed about 6L, taking into consideration the
need to not decrease his preload in the setting of AS in order
to maintain his CO. Renal was consulted for his elevated Cr,
which occurred likely secondary to poor forward flow state and
suggested an SPEP/UPEP, which was negative for Bence [**Doctor Last Name **]
protein. His lasix drip was d/c and he continued to
auto-diurese. His Toresmide was restarted and a Heart Failure
consult was requested.

MEDICAL HISTORY: Diabetes
Dyslipidemia
CAD s/p PCA in [**1-/2182**]
CHF EF 25-30% ([**7-27**])
Moderate Aortic Stenosis
Mild->Moderate AR
Moderate MR
[**First Name (Titles) **] [**Last Name (Titles) 71133**]
Anemia
CKD (baseline creatinine difficult to assess 2-2.7)
Gout
Recent GI bleed thought [**2-19**] [**Month/Day (2) 4532**], no scope
H. pylori positive [**7-18**] (was being treated prior to hospital)

MEDICATION ON ADMISSION: Atorvastatin 80 mg Tablet DAILY
Glipizide 10 mg Tablet DAILY
Metoprolol Tartrate 12.5 mg Tablet [**Hospital1 **]
NitroQuick 0.4 mg Tablet, Sublingual prn chest pain (not used)
Pantoprazole 40 mg Tablet [**Hospital1 **]
Torsemide 20 mg Tablet in am, 10 in pm
Acetaminophen 500 mg
Aspirin 81 mg
Ferrous Sulfate 325 mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: Arousable to voice, Oriented x2
HEENT: MMD
Neck: supple, JVP elevated
Lungs: +rhales b/l
CV: +systolic murmur. S1+, S2+
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: +foley
Ext: +edema to thigh b/l.

FAMILY HISTORY: No family history of breast, colon, or prostate cancer. Brother
had heart disease. Children in good health.

SOCIAL HISTORY: The patient was born in [**Country 4754**]. He lives in [**Location 1268**] with
his wife, with whom he has two daughters and a son. [**Name (NI) **] denies
any history of tobacco or drug use. He drinks alcohol in small
amounts, occasionally (on the weekend). 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage IV (severe),Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Helicobacter pylori [H. pylori],Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Gout, unspecified,Prickly heat,Contact dermatitis and other eczema, unspecified cause,Anemia, unspecified,Photokeratitis'}
