CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 83yo M with h/o HTN, DLP, CHF, A fib s/p permanent pacemaker
(4/'[**04**]), anterior MI s/p CABG ([**2084**]), AAA with multiple repairs,
CVA presents with shortness of breath.
.
Patient's cardiac history dates back to [**2084**] when he developed
chest pain and was found to have an anterior MI. He received a
CABG in [**2084**] and has been chest pain free since then.
.
Patient first experienced shortness of breath on exertion about
five years ago, when he was placed on Lasix with adequate
management of his symptoms until recently. Patient's EF as
reported by echo in [**2102**] and in [**2104-7-6**] was stable at 30-35%.

MEDICAL HISTORY: Cardiac Risk Factors:
- Hypertension
- Dyslipidemia
- s/p Prior anterior MI [**2084**]
.
Cardiac History: CABG ([**2084**]), anatomy as follows:
- LIMA to LAD, SVG to RCA
.
No PCI (most recent cardiac catheterization [**2084**])
.
ICD placed [**2104-6-5**] for symptoms attributed to atrial
fibrillation.
.
Other Past History:
- CHF, most recent Echo [**2104-9-23**] with EF ~15%, severe MR (Echo
[**2104-5-5**] and [**2104-7-14**] with EF 30%)
- Atrial fibrillation, diagnosed [**5-/2104**]
- CVA [**5-/2104**] with UE hemiparesis x1 week
- Abdominal Aortic Aneurysm [**2095**] with multiple endograft repairs
- [**Hospital1 **]-fem bypass several years prior
- Bilateral inguinal hernias
- h/o Rectal bleed [**2100**]
.

MEDICATION ON ADMISSION: - Toprol XL 25mg daily
- Lasix 80mg tid (recently discontinued)
- Lisinopril 5mg (discontinued 7/'[**04**])
- Metolazone 2.5mg 3x per week (M, W, F)
- ASA 81mg daily
- Coumadin 5mg daily (initiated 4/'[**04**], held since [**2104-9-21**])
- Simvastatin 10mg daily
- Protonix 20mg daily (initiated 1 month ago)
- PRN Nitroglycerin patch
- Tylenol prn arthritic pain
.
ALLERGIES: PCN (hives), Celebrex, Plaquenil (unknown reaction)

ALLERGIES: Penicillins / Celebrex / Plaquenil / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS - T 98.0 P 78 BP 98/64 R 20 94% RA
Gen: Alert, interactive, WDWN male in mild respiratory distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Pale conjunctiva. No
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP ~14cm to earlobes. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Grade I systolic murmer at RUSB, Grade II
systolic murmer at apex. No thrills, lifts. Occasional S4.
Chest: Mild pectus excavatum. Resp were minimally labored but
without accessory muscle use. Fine crackles to mid-lung on
right, fine crackles in lower lobes on left. Minimal
end-expiratory wheezes in upper lobes b/l.
Abd: Soft, NT, mildly distended. +BS. No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. Cool LE's.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Non-suppurative, non-tender, non-erythematous scaly brown
lesions on mid-plantar surface of left foot.
Neuro exam: Alert, oriented. PERRL, EOMI, CNs symmetric and
intact. Strength 5/5 bilaterally in upper extremities, 4+/5
bilaterally in legs. Gait not assessed secondary to dyspnea.
Rapid alternating movements of fingers intact.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Mother had a heart condition of uncertain
nature, died at [**Age over 90 **]yo. Father had h/o lung cancer.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, 120 pk-yr history of prior tobacco use (x60 years, quit
[**2084**]). There is no history of alcohol abuse.
.
Patient previously employed as mechanical contractor, plumber,
handyman repairing heating and air conditioning units.
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Other specified forms of chronic ischemic heart disease,Mitral valve disorders,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Ac on chr syst hrt fail,Acute kidney failure NOS,Gastrointest hemorr NOS,React-indwell urin cath,Urin tract infection NOS,Hyposmolality,Late ef-hemplga side NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Postinflam pulm fibrosis,Anemia NOS,Chr ischemic hrt dis NEC,Mitral valve disorder,Abn react-urinary cath
Admission Date:  [**2104-9-24**]              Discharge Date:   [**2104-10-7**]


Service: MEDICINE

Allergies:
Penicillins / Celebrex / Plaquenil / Sulfa (Sulfonamides)

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

Major Surgical or Invasive Procedure:
[**Hospital1 **]-ventricular pacemaker upgrade
Trans-esophageal Echocardiogram
Cardioversion
EGD (Esophago-gastro-duodenoscopy)
Colonoscopy


History of Present Illness:
83yo M with h/o HTN, DLP, CHF, A fib s/p permanent pacemaker
(4/'[**04**]), anterior MI s/p CABG ([**2084**]), AAA with multiple repairs,
CVA presents with shortness of breath.
.
Patient's cardiac history dates back to [**2084**] when he developed
chest pain and was found to have an anterior MI. He received a
CABG in [**2084**] and has been chest pain free since then.
.
Patient first experienced shortness of breath on exertion about
five years ago, when he was placed on Lasix with adequate
management of his symptoms until recently. Patient's EF as
reported by echo in [**2102**] and in [**2104-7-6**] was stable at 30-35%.

.
Patient's most recent symptoms became apparent beginning in
[**2104-5-6**] when he began to experience progressive episodes of
shortness of breath and fatigue. Symptoms began following a
stroke which occurred in [**2104-4-5**], which resulted in left arm
hemiparesis that resolved with physical therapy. Workup for the
stroke revealed that the patient was in atrial fibrillation, and
patient was placed on Coumadin. He began experiencing worsening
dyspnea on exertion and
had multiple medication adjustments of his HF regimen with
suboptimal response. As a result, an ICD was placed [**2104-6-5**] for
what was believed to be symptomatic a fib. Patient was also
subsequently cardioverted in [**2104-6-5**] for continued dyspnea on
exertion.
.
Patient reported worsening of dyspnea following placement of
ICD, with PND, orthopnea which was minimally relieved when
sitting up in a chair at night, inability to sleep due to
shortness of breath. Patient's activity tolerance also
decompensated from being able to walk and play golf without
shortness of breath in [**2104-5-6**] to his current state, where he
becomes dyspneic at rest. Patient also reports that he began to
experience hemoptysis of dark red sputum in the past two weeks.
He has noticed a bloated abdomen with nausea and feelings of
fullness for the past 4 months as well. Patient denies chest
pain, but reports that he experienced a mild tightness in his
chest with the episodes of dyspnea.
.
Patient was recently found by his cardiologist to have a low BP
in the upper 70's and upper 80's, and his Lisinopril was
discontinued and Lasix was stopped. Lasix was reinitiated and
stopped several times in an attempt to prevent hypotension while
treating symptoms of dyspnea.
.
Patient presented and was admitted to Upper [**Hospital 2748**] [**Hospital **]
Hospital [**9-21**] for continued worsening symptoms, and was believed
to be "profoundly azotemic." He was given IV fluids without any
improvement of dyspnea, and was re-initiated on Lasix briefly.
During his hospital stay at the OSH 2 days prior to presentation
at [**Hospital1 18**], per family, patient developed hypothermia of 90
degrees F. Family reports that patient was wrapped in multiple
blankets at the hospital, and his temperature increased to 92
degrees F.
.
CXR was obtained at OSH on [**9-23**] which showed cardiomegaly with
fine bibasilar markings. An echo obtained [**9-23**] at OSH showed
worsened MR (3+) with worsened EF ~15%. CT chest with IV
contrast was obtained at the OSH as well, which resulted in
elevation of patient's Cr from baseline of 0.9-1.5 to 3.4.
.
The plan at the OSH was to transfer the patient to [**Hospital **]
[**Hospital3 26522**] Center, but patient's family decided to seek
care at [**Hospital1 18**] and drove patient to [**Location (un) 86**]. On presentation, he
was mildly dyspneic on 3L O2 NC with sats in the low 90's.
However, patient reported that he felt his breathing was
improved. He has remained asymptomatic of chest pain since
admission, and had one episode of dyspnea and drops of sats into
80's following bedside TTE, which resolved following elevation
of the head of the bed and increase of oxygen to 4L. He is
currently breathing comfortably on 4L NC without use of
accessory muscles.
.


Past Medical History:
Cardiac Risk Factors:
- Hypertension
- Dyslipidemia
- s/p Prior anterior MI [**2084**]
.
Cardiac History: CABG ([**2084**]), anatomy as follows:
- LIMA to LAD, SVG to RCA
.
No PCI (most recent cardiac catheterization [**2084**])
.
ICD placed [**2104-6-5**] for symptoms attributed to atrial
fibrillation.
.
Other Past History:
- CHF, most recent Echo [**2104-9-23**] with EF ~15%, severe MR (Echo
[**2104-5-5**] and [**2104-7-14**] with EF 30%)
- Atrial fibrillation, diagnosed [**5-/2104**]
- CVA [**5-/2104**] with UE hemiparesis x1 week
- Abdominal Aortic Aneurysm [**2095**] with multiple endograft repairs
- [**Hospital1 **]-fem bypass several years prior
- Bilateral inguinal hernias
- h/o Rectal bleed [**2100**]
.


Social History:
Social history is significant for the absence of current tobacco
use, 120 pk-yr history of prior tobacco use (x60 years, quit
[**2084**]). There is no history of alcohol abuse.
.
Patient previously employed as mechanical contractor, plumber,
handyman repairing heating and air conditioning units.

Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had a heart condition of uncertain
nature, died at [**Age over 90 **]yo. Father had h/o lung cancer.


Physical Exam:
VS - T 98.0 P 78 BP 98/64 R 20 94% RA
Gen: Alert, interactive, WDWN male in mild respiratory distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Pale conjunctiva. No
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP ~14cm to earlobes. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Grade I systolic murmer at RUSB, Grade II
systolic murmer at apex. No thrills, lifts. Occasional S4.
Chest: Mild pectus excavatum. Resp were minimally labored but
without accessory muscle use. Fine crackles to mid-lung on
right, fine crackles in lower lobes on left. Minimal
end-expiratory wheezes in upper lobes b/l.
Abd: Soft, NT, mildly distended. +BS. No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. Cool LE's.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Non-suppurative, non-tender, non-erythematous scaly brown
lesions on mid-plantar surface of left foot.
Neuro exam: Alert, oriented. PERRL, EOMI, CNs symmetric and
intact. Strength 5/5 bilaterally in upper extremities, 4+/5
bilaterally in legs. Gait not assessed secondary to dyspnea.
Rapid alternating movements of fingers intact.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
.


Pertinent Results:
[**2104-9-24**]  URINE  HOURS-RANDOM UREA N-500 CREAT-94 SODIUM-LESS
THAN  POTASSIUM-48 CHLORIDE-LESS THAN
[**2104-9-24**] 03:05PM   GLUCOSE-132* UREA N-123* CREAT-4.1*
SODIUM-125* POTASSIUM-4.6 CHLORIDE-80* TOTAL CO2-27 ANION
GAP-23*
[**2104-9-24**] 03:05PM   ALT(SGPT)-22 AST(SGOT)-22 LD(LDH)-282*
CK(CPK)-69 ALK PHOS-69 TOT BILI-0.8
[**2104-9-24**] 03:05PM   CK-MB-6 cTropnT-0.14* proBNP-GREATER TH
[**2104-9-24**] 03:05PM   ALBUMIN-4.1 CALCIUM-8.9 PHOSPHATE-6.2*
MAGNESIUM-3.5*
[**2104-9-24**] 03:05PM   DIGOXIN-1.0
[**2104-9-24**] 03:05PM   WBC-8.6 RBC-3.50* HGB-10.9* HCT-32.1* MCV-92
MCH-31.1 MCHC-33.9 RDW-15.9*
[**2104-9-24**] 03:05PM   NEUTS-83.1* LYMPHS-11.1* MONOS-5.0 EOS-0.6
BASOS-0.2
[**2104-9-24**] 03:05PM   PT-32.7* PTT-40.4* INR(PT)-3.4*
.
CXR on Admission [**2104-9-24**]: There is no comparison available.
[**Month/Day/Year **] enlargement of the cardiac silhouette, pacemaker in
situ. [**Month/Day/Year **] aortic tortuosity of the thoracic aorta. The lung
volumes are low and show bilateral blunting of costophrenic
sinus and increase in interstitial structures that have fibrotic
appearance. There are no signs of additional pneumonia and no
signs suggestive of overhydration. Clips of the bypass surgery,
abdominal aortic stent graft in situ.
.
Echocardiogram ([**2104-9-24**]): The left atrial volume is markedly
increased (>32ml/m2). Color-flow imaging of the interatrial
septum raises the suspicion of an atrial septal defect, but this
could not be confirmed on the basis of this study. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 15-20 %). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. [**Month/Day/Year **] to severe
(3+) mitral regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. Severe pulmonic regurgitation is seen. There is no
pericardial effusion. IMPRESSION: Severe global biventricular
systolic dysfunction. The anterior wall and septum are akinetic.
The LV and RV are dilated. Severe mitral regurgitation, [**Month/Day/Year 1192**]
tricuspipd regurgitation. Possible atrial septal defect.
.
CHEST CT WITHOUT CONTRAST IMPRESSION ([**2104-9-29**]):
1. Findings consistent with pulmonary fibrosis, which can be due
to chronic hypersensitivity pneumonitis. Superimposed
ground-glass opacities can be seen in the setting of pulmonary
hemorrhage, which would be consistent with given history of
hemoptysis. Pulmonary infection cannot be excluded. The findings
are not typical for asbestosis. Amiodarone toxicity can present
with similar imaging findings and can be considered if patient
was treated with amiodarone. 2. Several noncalcified pulmonary
nodules, largest measuring 10 mm, three- month followup chest CT
is recommended. FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities. 3. Dense atherosclerotic
coronary artery calcifications, status post bypass graft
procedure. 4. Basal bronchiectasis, which can be seen in the
setting of chronic aspiration. 5. No evidence of CHF.
.
CXR on discharge [**2104-10-5**]: Comparison with the previous study
done [**2104-10-2**]. Evidence for mild interstitial edema persists.
Heart appears enlarged as before. The patient is status post
median sternotomy. Mediastinal structures are unchanged. A
pacemaker remains in place.




Brief Hospital Course:
Patient is an 83 year old male with history of ischemic
cardiomyopathy with newly further depressed ejection fraction,
severe mitral regurgitation, atrial fibrillation status post
failed cardioversion in [**2104-6-5**], status-post ICD/pace-maker,
who was transferred to [**Hospital1 18**] for further management of dypsnea
and his cardiac problems.

Patient arrived on the floor and was very dyspneic with minimal
exertion. His laboratories were remarkable for creatinine of
4.1, sodium of 132, and INR of 3.4. He was also noted to have
mild hemoptysis.

Hospital course is as followed by system:

#) Congestive heart failure, history of ischemic cardiomyopathy:
Per report from patient's outside hospital, an echocardiogram
was completed prior to transfer that demonstrated a worsened
ejection fraction of 15%, with severe mitral regurgitation (as
compared to echocardiogram from [**2104-6-5**] where his EF was
approximately 30% and MR [**First Name (Titles) **] [**Last Name (Titles) 1192**]). On exam, he appeared
fluid overloaded with rales bilaterally and elevated JVP. A
chest x-ray was completed at admission as well as a bedside
echocardiogram, which confirmed the above findings. Patient was
started on a lasix drip after he failed to diuresis to lasix
boluses on night of admission; a goal urine output of 60cc/hr
was maintained. Hydralazine was added for afterload reduction as
well given his severe mitral regurgitation.

The next day, patient was transferred to the cardiac intensive
care unit for further monitoring and possible Swanz placment
given that he was still very dyspneic with minimal exertion (eg
moving in bed) and possible ionotropic support for diuresis. He
received Diuril in addition to his lasix drip, and continued to
have good diuresis. He was transferred back to the cardiology
floor the next day.

Given that the the patient's symptoms appeared to have worsened
around the time of his pacermaker placement, and he had failed
cardioversion, it was felt that he may have some benefit from a
[**Hospital1 **]-ventricular pacemaker. An electrophysiology (EP) consult was
obtained, and plans were made for placement of a biventricular
pacemaker to help his cardiac output, as he was being paced
approximately 90% of the time. It was also felt that a
tranesophageal echocardiogram (TEE), followed by cardioversion
if no clot was seen, would also be of benefit to give the
patient better cardiac output with "atrial kick."

Patient underwent an upgrade of his pacemaker to a
[**Hospital1 **]-ventricular pacemaker on [**2104-10-1**] and reported improvement in
his symptoms.

He underwent a TEE with subsequent cardioversion on [**2104-10-3**] and
again reported improvement in his symptoms.

He continued to diurese well on the lasix drip, which was
transitioned to intravenous lasix doses and then an oral regimen
(120mg PO daily). At time of discharge, his weight was down over
4 kilograms.

Because of some low blood pressures in hospital his Toprol XL
was restarted at half his dose (25mg [**2-6**] tab daily) His
hydralazine was restarted. An ace-inhibitor or [**Last Name (un) **] was not
started due to his renal function, which improved but continued
to be variable. His digoxin was stopped given his variable renal
function and decompensated failure at time of admission.

He has an ICD in place for primary prevention given his low
ejection fraction. He is on anticoagulation for that as well as
his atrial fibrillation and history of CVA.

If patient continues to have further symptoms from his mitral
regurgitation, mitral valve replacement might be a
consideration, however that was no pursued during this admission
given the improvement in his symptoms with medical therapy and
his multiple other co-morbidities.

#) Gastrointestinal bleed:
On [**2104-9-28**] the patient developed three episodes of bloody stools
which were maroon in color mixed with a significant quantity of
stool.  He did not have any subsequent bowel movements or
hematochezia, and was asymptomatic apart from minimal dizziness
following the bowel movements. Given concern for acute
gastrointestinal bleeding from either an upper or lower source,
patient's anti-coagulation was held (he had been on a heparin
drip after his INR was <2.0); his diuresis and beta-blocker were
temporarily stopped. He was started on an intravenous proton
pump inhibitor and maintained on clears. The gastroenterology
team was consulted for further evaluation, and on [**2104-10-2**], the
patient underwent upper endoscopy and colonoscopy. Records were
obtained from the patient's prior colonoscopy, which was from
[**2099**], demonstrating no significant findings. There was some
erosion and friability of the gastric mucosa, however no
bleeding was located. Biopsies of the gastric mucosa and h.
pylori serologies were pending at time of discharge and should
be followed up. It was felt that it was safe to resume
anticoagulation. The prior bleeding was felt to likely be due to
gastritis or an ulcer, which had resolved. He should continue
twice daily proton pump inhibitor until follow up with his
primary care provider or [**Name Initial (PRE) **] gastroenterologist. He had no further
episodes of bleeding and his hematocrit remained stable.

#) Coronary artery disease: Patient has ischemic cardiomyopathy
as evidenced by echocardiogram, and is status post CABG for a
myocardial infarction in [**2084**]. During his stay, he had no
symptoms concerning for acute coronary syndrone. He was
continued on his aspirin once he had no evidence of bleeding, as
well as metoprolol and his statin.

#) Rhythm: Patient has a Pacemaker/ICD in place for history of
atrial fibrillation and for primary prevention given his low
ejection fraction. He had a few episodes of NSVT (less than 10
beats) at the time of his prep for his colonoscopy, with
accompanying electrolyte distrubances, which were felt to be the
cause. He had no further episodes once his electrolyte
abnormalities resolved.

Patient underwent upgrade of his biventricular pacemaker as well
as a TEE with cardioversion as described above. He was started
on an amiodarone load to prevent recurrance of atrial
fibrillation. He will ultimately take 200 mg daily for
maintenance.

His anticoagulation was continued for his history of atrial
fibrillation. His coumadin dose was lowered due to the fact that
he was started on amiodarone.

#) Acute on Chronic Renal Failure: Based on records accompanying
patient, his baseline creatinine appears to range between 0.9 -
1.4 until [**2104-6-5**], at which time it was in the mid 2's. At time
of transfer, his creatinine had risen to over 3, and upon
arrival it was over 4. It was felt that he likely had acute
tubular necrosis from the contrast given to the patient for a
CTA done prior to his transfer, coupled with his low flow state
due to his decompensated congestive heart failure. His
creatinine peaked at 4.4, and then stabalized in the 1.7 to 2.3
range.

#) Hemoptysis: Patient has been experiencing hemoptysis for 2
weeks prior to arrival, which has been dark about half a
spoonful of dark red blood mixed with sputum. It was felt that
was likely secondary to pulmonary edema and subsequent pulmonary
vascular dilation in the setting of supratherapeutic INR. A
pulmonary consult was obtained for further evaluation and
recommendations regarding anticoagulation. His hemoptysis
improved and resolved as his INR normalized. His outside
imaging, including the CTA of this chest was reviewed, and a
repeat CAT scan without contrast was obtained after diuresis to
rule out any signs of malignancy, given his long tobacco use
history and asbestosis exposure. No large lesions were seen,
however "several noncalcified pulmonary nodules, largest
measuring 10 mm" were reported. Patient should have a repeat
chest CT in three months to follow up. The radiology report
notes that a FDG-PET can be non-conclusive in the setting of
surrounding ground-glass opacities.

#) Interstitial Pulmonary Fibrosis: No acute issues. Patient was
weaned off of oxygen. Repeat CAT scan as noted in results.

#) Elevated INR: Patient's Coumadin was held beginning [**9-21**],
however his INR was still 3.4 at admission. He was given vitamin
K to further lower his INR in the event that he needed any
procedures. He was maintained on a heparin drip after his
gastrointestinal work-up and bridged back to coumadin.  His INR
was 1.9 on the day of discharge.

#) Anemia: Patient has anemia, which may be due to combination
of renal insufficiency and heart failure. His work up for
gastrointestinal bleeding is as noted above. Iron studies were
obtained and revealed an iron of 26, TIBC of 286, ferritn 260,
and transferritin of 220. He should continue to follow up with
his primary provider for further management of his anemia. He
did not receive any blood transfusions, and his hematocrit
remained stable in the 28-32 range.
.
#) HTN: Patient's blood pressure has been in low 100's and high
90's since admission, likely due to his heart failure. He had no
problems with hypertension during his stay, and his blood
pressure actually remained on the low side, without symptoms.
.
#) Dyslipidemia: Continued home statin dose.
.
#) Possible Sleep Apnea: Consider assessment after patient's
acute cardiac issues have resolved.
.
#) Urinary tract infection: Patient was noted to have an urine
analysis consistent with infection. He had had a foley in place
to monitor diuresis and due to his severe dyspnea with any
exertion. The foley was removed and he completed a course of
treatment with vancomycin given his pencillin allergy.
.
#) Code: Full code.
.
#) Discharge: Patient was evaluated by physical therapy and felt
to be safe for discharge home without services. He had a very
supportive family that was involved in his care. He will follow
up closely with his local cardiologist for a device check and
cardiology appointment.

Medications on Admission:
- Toprol XL 25mg daily
- Lasix 80mg tid (recently discontinued)
- Lisinopril 5mg (discontinued 7/'[**04**])
- Metolazone 2.5mg 3x per week (M, W, F)
- ASA 81mg daily
- Coumadin 5mg daily (initiated 4/'[**04**], held since [**2104-9-21**])
- Simvastatin 10mg daily
- Protonix 20mg daily (initiated 1 month ago)
- PRN Nitroglycerin patch
- Tylenol prn arthritic pain
.
ALLERGIES: PCN (hives), Celebrex, Plaquenil (unknown reaction)


Discharge Disposition:
Home With Service

Facility:
Upper [**Hospital 2748**] Hospital Home Health Agency

Discharge Diagnosis:
Primary Diagnosis:
 - Decompensated Heart Failure

Secondary Diagnosis:
 - Chronic atrial fibrillation
 - Acute renal failure
 - Spontaneous GI bleed
 - Severe mitral regurgitation


Discharge Condition:
Stable, ambulating without difficulty, cleared by physical
therapy for discharge. On room air.


Discharge Instructions:
You were admitted for further management of your heart failure,
respiratory distress, and atrial fibrillation. You were treated
with several medications. You underwent an upgrade of your
pacemaker as well as cardioversion after transesophageal
echocardiogram. You also underwent an upper endoscopy and
colonoscopy to ensure you had no active gastrointestinal
bleeding.

Please contact your primary care physician, [**Name10 (NameIs) 2085**], or go
to the emergency room if you experience any shortness of breath,
chest pain, headaches, dizziness, bleeding, or other concerning
symptoms.

A number of medication changes have been made, so please review
the changes closely.

You will need to have your coumadin level (INR) followed closely
(once a week until your amiodarone dose is stable) because of
the effect amiodarone has on coumadin levels. You will also need
to have pulmonary function tests completed and have an eye exam
when you return to your home town while on amiodarone.

Please weigh yourself every morning, and call your physician if
your weight increases more than 3 lbs. Please adhere to 2 gram
sodium diet, and limit your fluid intake to 1500 mL daily.

A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am.  Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**].  In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment.  A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].

Followup Instructions:
A follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] was scheduled on
[**10-14**] at 11:30am.  Dr.[**Name (NI) 79032**] phone number is
[**Telephone/Fax (1) 79033**].  In addition to general cardiac follow-up, your
[**Hospital1 **]-ventricular pacemaker will be checked at this appointment.  A
copy of your medical information from this hospital stay will be
faxed to Dr. [**Last Name (STitle) 9404**] at [**Telephone/Fax (1) 79034**]. You should have your INR
(coumadin level) checked regularly (weekly at first given
changes in your medications).
.
A follow-up appointment was also made with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 79035**] for [**10-27**] at 3:45pm.
His phone number is [**Telephone/Fax (1) 79036**].
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Other specified forms of chronic ischemic heart disease,Mitral valve disorders,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: 83yo M with h/o HTN, DLP, CHF, A fib s/p permanent pacemaker
(4/'[**04**]), anterior MI s/p CABG ([**2084**]), AAA with multiple repairs,
CVA presents with shortness of breath.
.
Patient's cardiac history dates back to [**2084**] when he developed
chest pain and was found to have an anterior MI. He received a
CABG in [**2084**] and has been chest pain free since then.
.
Patient first experienced shortness of breath on exertion about
five years ago, when he was placed on Lasix with adequate
management of his symptoms until recently. Patient's EF as
reported by echo in [**2102**] and in [**2104-7-6**] was stable at 30-35%.

MEDICAL HISTORY: Cardiac Risk Factors:
- Hypertension
- Dyslipidemia
- s/p Prior anterior MI [**2084**]
.
Cardiac History: CABG ([**2084**]), anatomy as follows:
- LIMA to LAD, SVG to RCA
.
No PCI (most recent cardiac catheterization [**2084**])
.
ICD placed [**2104-6-5**] for symptoms attributed to atrial
fibrillation.
.
Other Past History:
- CHF, most recent Echo [**2104-9-23**] with EF ~15%, severe MR (Echo
[**2104-5-5**] and [**2104-7-14**] with EF 30%)
- Atrial fibrillation, diagnosed [**5-/2104**]
- CVA [**5-/2104**] with UE hemiparesis x1 week
- Abdominal Aortic Aneurysm [**2095**] with multiple endograft repairs
- [**Hospital1 **]-fem bypass several years prior
- Bilateral inguinal hernias
- h/o Rectal bleed [**2100**]
.

MEDICATION ON ADMISSION: - Toprol XL 25mg daily
- Lasix 80mg tid (recently discontinued)
- Lisinopril 5mg (discontinued 7/'[**04**])
- Metolazone 2.5mg 3x per week (M, W, F)
- ASA 81mg daily
- Coumadin 5mg daily (initiated 4/'[**04**], held since [**2104-9-21**])
- Simvastatin 10mg daily
- Protonix 20mg daily (initiated 1 month ago)
- PRN Nitroglycerin patch
- Tylenol prn arthritic pain
.
ALLERGIES: PCN (hives), Celebrex, Plaquenil (unknown reaction)

ALLERGIES: Penicillins / Celebrex / Plaquenil / Sulfa (Sulfonamides)

PHYSICAL EXAM: VS - T 98.0 P 78 BP 98/64 R 20 94% RA
Gen: Alert, interactive, WDWN male in mild respiratory distress.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Pale conjunctiva. No
pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP ~14cm to earlobes. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Grade I systolic murmer at RUSB, Grade II
systolic murmer at apex. No thrills, lifts. Occasional S4.
Chest: Mild pectus excavatum. Resp were minimally labored but
without accessory muscle use. Fine crackles to mid-lung on
right, fine crackles in lower lobes on left. Minimal
end-expiratory wheezes in upper lobes b/l.
Abd: Soft, NT, mildly distended. +BS. No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. Cool LE's.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Non-suppurative, non-tender, non-erythematous scaly brown
lesions on mid-plantar surface of left foot.
Neuro exam: Alert, oriented. PERRL, EOMI, CNs symmetric and
intact. Strength 5/5 bilaterally in upper extremities, 4+/5
bilaterally in legs. Gait not assessed secondary to dyspnea.
Rapid alternating movements of fingers intact.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Mother had a heart condition of uncertain
nature, died at [**Age over 90 **]yo. Father had h/o lung cancer.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, 120 pk-yr history of prior tobacco use (x60 years, quit
[**2084**]). There is no history of alcohol abuse.
.
Patient previously employed as mechanical contractor, plumber,
handyman repairing heating and air conditioning units. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis,Anemia, unspecified,Other specified forms of chronic ischemic heart disease,Mitral valve disorders,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
