CHIEF COMPLAINT: A.Fib RVR, hemodynamically unstable s/p mediastinoscopy

PRESENT ILLNESS: 62 year old female with history of HTN, CAD s/p DES to LCx/LAD
in [**10/2177**], severe PAH, biventricular diastolic dysfunction, and
mediastinal lymphadenopathy electively admitted to thoracic
surgery s/p mediastinoscopy yesterday with persistent hypoxia
and lactic acidosis.
.
Right and left heart cath in [**10/2177**] showed pulmonary artery
pressures of 67/23/46. Nuclear stress last month showed
uninterpretable ECG for ischemia due to abnormal baseline, with
appropriate hemodynamic response to Persantine. No anginal type
symptoms, a fixed mild decrease in septal activity may be
related to LBBB. Normal LV wall motion and systolic function,
with hyperdynamic LVEF of 85%.
.
During this admission, she was noted to have an oxygen
saturation of 90% in pre-op and was hypotensive during the case,
to the 60s systolic, and required ephedrine and neo to maintain
her BPs. Bronchoscopy showed clear secretions. In the PACU she
was extubated and continued to have low O2 sats 88-90% on 3
liters N/C, although both the patient and her daughter explained
that this is her baseline and she does not use home oxygen. She
reported taking her home lisinopril and atenolol the morning of
the mediastinoscopy. She did not take her Lasix. She was also
unable to void in the PACU and when a foley was placed she
urinated 200cc. Her urine output in PACU reached a low of 17
cc/hour but averaged 20-30 cc/hour overnight. She had an initial
VBG that was 7.29/35/26 and a lactate of 5. On repeat VBG four
hours later it was 7.30/34/43 and lactate was 5 again. She was
transferred to Medicine for management of her lactic acidosis
and hypoxia.

MEDICAL HISTORY: Past Medical History:
DM
CAD s/p LAD cypher stenting
occult SBE with aortiv valve vegetation
severe pHTN
HTN
HLD
.
Past Sx History:
Rt Fem-[**Doctor Last Name **] bypass
Rt CEA following CVA prior to [**2173**]
Lt CEA following TIA [**2173**]
Stenting of LCx DPromus [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent

MEDICATION ON ADMISSION: 1. ALENDRONATE 70 mg weds - (pt does not taking this medication)
2. CILOSTAZOL 100 mg [**Hospital1 **]
3. CLOPIDOGREL 75 mg qd
4. GLYBURIDE 5 qd
5. LISINOPRIL 20 qd
6. METFORMIN 1,000 [**Hospital1 **]
7. METOPROLOL SUCCINATE [TOPROL XL] 200 qd
8. NIACIN 500 [**Hospital1 **]
9. OMEPRAZOLE 20 qd
10. PREGABALIN 100 [**Hospital1 **]
11. SIMVASTATIN 40 qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 98.3 BP: 108/91 (rechecked at 7 AM 89/61) P:158
(rechecked 134) R: 24 on NRB (19 on BiPAP) O2:  96% on 50% o2
General: Alert, oriented, on NRB
HEENT: Sclera slightly icteric, MMM, oropharynx clear
Neck: Mediastonsocpy site near jugular notch appears CDI. JVP
elevated to below jaw line at 75 degrees.
Lungs: Coarse rhonchi/crackles in lower lung fields bilaterally
left worse than right.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis 1+
edema
surgical scars consistent with revascularization procedures.
.
Discharge Physical Exam:

FAMILY HISTORY: Father had MI in his 50's and stroke in his 60's.  Siblings with
DM.

SOCIAL HISTORY: Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies
Enlargement of lymph nodes,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Primary pulmonary hypertension,Acidosis,Acute kidney failure, unspecified,Atrial flutter,Other iatrogenic hypotension,Hypercalcemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery
Enlargement lymph nodes,Ac on chr diast hrt fail,Pneumonia, organism NOS,Prim pulm hypertension,Acidosis,Acute kidney failure NOS,Atrial flutter,Iatrogenc hypotnsion NEC,Hypercalcemia,Hypertension NOS,Crnry athrscl natve vssl
Admission Date:  [**2178-9-3**]              Discharge Date:   [**2178-9-28**]

Date of Birth:  [**2116-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
A.Fib RVR, hemodynamically unstable s/p mediastinoscopy

Major Surgical or Invasive Procedure:
mediastinoscopy

History of Present Illness:
62 year old female with history of HTN, CAD s/p DES to LCx/LAD
in [**10/2177**], severe PAH, biventricular diastolic dysfunction, and
mediastinal lymphadenopathy electively admitted to thoracic
surgery s/p mediastinoscopy yesterday with persistent hypoxia
and lactic acidosis.
.
Right and left heart cath in [**10/2177**] showed pulmonary artery
pressures of 67/23/46. Nuclear stress last month showed
uninterpretable ECG for ischemia due to abnormal baseline, with
appropriate hemodynamic response to Persantine. No anginal type
symptoms, a fixed mild decrease in septal activity may be
related to LBBB. Normal LV wall motion and systolic function,
with hyperdynamic LVEF of 85%.
.
During this admission, she was noted to have an oxygen
saturation of 90% in pre-op and was hypotensive during the case,
to the 60s systolic, and required ephedrine and neo to maintain
her BPs. Bronchoscopy showed clear secretions. In the PACU she
was extubated and continued to have low O2 sats 88-90% on 3
liters N/C, although both the patient and her daughter explained
that this is her baseline and she does not use home oxygen. She
reported taking her home lisinopril and atenolol the morning of
the mediastinoscopy. She did not take her Lasix. She was also
unable to void in the PACU and when a foley was placed she
urinated 200cc. Her urine output in PACU reached a low of 17
cc/hour but averaged 20-30 cc/hour overnight. She had an initial
VBG that was 7.29/35/26 and a lactate of 5. On repeat VBG four
hours later it was 7.30/34/43 and lactate was 5 again. She was
transferred to Medicine for management of her lactic acidosis
and hypoxia.

Past Medical History:
Past Medical History:
DM
CAD s/p LAD cypher stenting
occult SBE with aortiv valve vegetation
severe pHTN
HTN
HLD
.
Past Sx History:
Rt Fem-[**Doctor Last Name **] bypass
Rt CEA following CVA prior to [**2173**]
Lt CEA following TIA [**2173**]
Stenting of LCx DPromus [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent


Social History:
Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies


Family History:
Father had MI in his 50's and stroke in his 60's.  Siblings with
DM.


Physical Exam:
Admission Physical Exam:
Vitals: T: 98.3 BP: 108/91 (rechecked at 7 AM 89/61) P:158
(rechecked 134) R: 24 on NRB (19 on BiPAP) O2:  96% on 50% o2
General: Alert, oriented, on NRB
HEENT: Sclera slightly icteric, MMM, oropharynx clear
Neck: Mediastonsocpy site near jugular notch appears CDI. JVP
elevated to below jaw line at 75 degrees.
Lungs: Coarse rhonchi/crackles in lower lung fields bilaterally
left worse than right.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis 1+
edema
surgical scars consistent with revascularization procedures.
.
Discharge Physical Exam:


Pertinent Results:
[**2178-9-3**] 11:58PM   TYPE-[**Last Name (un) **] PO2-43* PCO2-34* PH-7.30* TOTAL
CO2-17* BASE XS--8
[**2178-9-3**] 11:58PM   LACTATE-5.0* K+-5.4*
[**2178-9-3**] 11:41PM   GLUCOSE-174* UREA N-34* CREAT-1.2*
SODIUM-130* POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-15* ANION
GAP-25*
[**2178-9-3**] 11:41PM   cTropnT-0.02*
[**2178-9-3**] 11:41PM   CALCIUM-8.6 PHOSPHATE-5.9* MAGNESIUM-1.9
[**2178-9-3**] 06:58PM   TYPE-ART TEMP-36.1 RATES-/20 PO2-26* PCO2-35
PH-7.29* TOTAL CO2-18* BASE XS--9 INTUBATED-NOT INTUBA
COMMENTS-O2 DELIVER
[**2178-9-3**] 04:46PM   CK(CPK)-56
[**2178-9-3**] 04:46PM   CK-MB-4 cTropnT-<0.01
[**2178-9-3**] 03:40PM OTHER BODY FLUID  CD23-DONE CD45-DONE
HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 7736**]7-DONE KAPPA-DONE CD10-DONE CD19-DONE CD20-DONE
LAMBDA-DONE CD5-DONE
[**2178-9-3**] 03:40PM OTHER BODY FLUID  CD3-DONE
[**2178-9-3**] 03:40PM OTHER BODY FLUID  IPT-DONE
.
MICRO:
.
IMAGING:
[**2178-9-3**] CXR - Lungs are well expanded. Compared to prior
radiograph, there is decrease in interstitial markings, upper
vascular redistribution and hilar engorgement. A right lower
lung radiopacity likely due to aspiration
pneumonia persists. Small bilateral pleural effusions are
present, no evidence of pneumothorax. Cardiomediastinal contour
is stable with a dilated pulmonary artery, unchanged from prior
radiograph
.
[**2178-9-7**] RUQ ultrasound
1. Mild intra-abdominal ascites.
2. Gallbladder wall thickening and pericholecystic fluid, likely
secondary to 3rd spacing and underlying cardiac disease. No
cholelithiasis or evidence of acute cholecystitis.
3. Limited evaluation of the pancreas and abdominal aorta due to
overlying
bowel gas.
.
PATHOLOGY
[**2178-9-3**] LN biopsy: FRAGMENT OF LYMPH NODE WITH REACTIVE FEATURES,
INCLUDING FOLLICULAR HYPERPLASIA, FOCAL PARACORTICAL HYPERPLASIA
AND SINUSOIDAL HISTIOCYTOSIS. THERE IS NO EVIDENCE OF LYMPHOMA.
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by non-Hodgkin B-cell
lymphoma are not seen in specimen. Correlation with clinical
findings and morphology is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas as due to
topography, sampling or artifacts of sample preparation.

Brief Hospital Course:
62 yo F with hx of severe of pulm HTN and CAD s/p DES to Lcx/LAD
in [**10/2177**] prior CVA s/p b/l CEA's, PVD who was transferred to
medicine after mediastinoscopy complicated by hypotension,
hypoxia, and lactic acidosis in the immediate post op period. In
brief, she came to medicine service on [**2178-9-4**] with lactic
acidosis and hypoxia, and was transferred to the medical ICU
early on [**2178-9-5**] after triggering for hypoxia and atrial flutter
with rates to 170s. On review, she had experienced 1-2 months of
progressive shortness of breath, > 20 lb weight gain, and
worsening lower extremity edema, likely representing worsening
congestive heart failure.

# Hypotension:
She was hypotensive during the mediastinoscopy, to the 60s
systolic, and required ephedrine and neo to maintain her BPs.
She reported taking her home lisinopril and atenolol the morning
of the mediastinoscopy. Her pressures recovered in the PACU.
Home beta blocker and lisinopril were held. Echo ([**2178-9-4**]) showed
signs of severe pulmonary artery hypertension with right
ventricle dilatation and moderate global free wall hypokinesis,
and septal motion consistent with increased RV pressures. On
exam, she had evidence of RHF including elevated JVP, pulsatile
liver, and bilat lower extremity edema. Thus, it was assumed
that intraoperatively she had poor forward flow from RV overload
and impairment of LV filling. Because of concern for
intraoperative MI, troponins were sent, which were initially
elevated and peaked to 0.67, but trended down, consistent with
demand ischemia. On [**2178-9-5**], she went into atrial flutter with
rates to the 170s and was transferred to the unit (see below).
Her rate was initially controlled on esmolal drip, with
subsequent hypotension to MAPS 50s with HR 100s. A RIJ was
placed and she was supported on neosyn. The esmolal drip was
stopped and she was loaded with amiodarone; her pressures
quickly responded and she was taken off of neosyn after a few
hours. Her SBPs have since been greater than 90.

# Lactic acidosis:
Post-op, VBG was 7.29/35/26 and on repeat 4 hrs later
7.30/34/43. Lactate was 5, attributed to hypotension and poor
forward flow during the procedure, with potential contribution
of Metformin. Her home metformin was held and she was started on
Lasix 20 mg IV bid. The metabolic acidosis quickly improved over
the post op day 1.

# Hypoxia:
In retrospect, was likely multifactorial with components of
pneumonia, pulmonary edema secondary to CHF, and likely COPD /
emphysema with long smoking history. Pre-procedure, she was
noted to have an oxygen saturation of 90%, but post-op in the
PACU continued to have low O2 sats 88-90% on 3 liters N/C after
extubation. CXR showed new consolidation in the RLL concerning
for pulmonary edema with overlapping right lower lobe
consolidation likely secondary to aspiration pneumonia and she
had WBCs 15.3. She was started empirically on Levofloxacin.
Shortly after transfer to medicine on [**9-4**], she triggered for
hypoxia, O2 sats 86% on 6L (as well as tachycardia and afib,
discussed below) and was transferred to the MICU where she was
started on BiPAP. Considering her tachycardia, hypoxia, and TTE
showing R sided overload and pulmonary HTN, there was some
concern for a PE. However, lack of chest pain, negative LENIs
and evidence of PNA on CXR to explain her symptoms supported low
suspicion for pulmonary embolism. [**Doctor Last Name 3012**] score was 1.5 for
tachycardia. Therefore, there was not sufficient evidence to
warrant Heparinization in a patient newly s/p mediastinoscopy
with high risk of medistinal bleeding. She was switched to
Vancomycin and Zosyn treated for HCAP with 8 day course with
improvement in her WBC and symtpoms. She was continued on
albuterol / ipratropium / Advair nebulizers with symptomatic
improvement. Her pulmonary edema was aggressively treated with
Lasix (see congestive heart failure below) with improvement of
her O2 sats until she was sating well at 92-100% on RA. She
continued to have intermittent O2 sats to 88-89% on RA and used
1 L NC to keep her O2 saturation > 92%.  By the time of
discharge, her oxygen saturation was 97-100% on 1L NC.

# Atrial fibrillation:
Early on the morning of [**2178-9-5**], the patient triggered for
tachycardia to the 170's with systolic blood pressures in the
low 100s. Her beta blocker had been held the day before because
of her hypotension. EKG appeared to be atrial flutter with 2:1
conduction. She was not complaining of any symptoms of SOB,
chest pain, or palpitations. She received 10 mg IV diltiazem,
and 20 mg IV lasix 2-3 hours prior to ICU evaluation (total 40
mg IV on day of transfer from thoracic surgery). She was
transferred to the ICU for rate control and hemodynamic
monitoring. Atrial fibrillation with RVR was thought most likely
secondary to developing PNA and recent mediastinoscopy. She was
loaded with Amiodarone and converted to sinus rhythm with
improvement in hemodynamic status.  After load she was started
on Amiodarone 400mg PO BID for 7 days. After 4 days in sinus on
amiodarone, she was switched to metoprolol after consultation
with her cardiologist, Dr. [**Last Name (STitle) **]. The patient remained in sinus
rhythm for the remainder of her hospitalization, with the
exception of 3 runs of VT, no more than 15 beats at a time.

# Elevated LFTs:
She had a mild LFT elevation that coincided an with initiation
of Amiodarone, however after consultation with pharmacy appeared
too early to be attributed to amiodarone. In retrospect, the LFT
elevation also coincided with her Afib and profound hypotension
in the unit, and thus may have been secondary to poor perfusion.
RUQ ultrasound was unremarkable. LFTs were followed for more
than two weeks and returned nearly to baseline levels but should
be rechecked at PCP visit this week.

#Elevated INR:
As above, seen in the setting of hypotension and atrial
fibrillation, however, may have been multifactorial with
contribution of malnutrition and initiation of broad spectrum
antibiotics. She received Vitamin K x 1 and her coags slowly
improved to baseline.  Pt will need LFTs followed up as an
outpatient.  Consider MRCP to evaluate bilairy tree if
persistently elevated.

# Rash:
She developed a cluster of [**7-10**] non-vesicular, round, ~ 1 cm
diameter, pruritic pink papules, at midline on her back; each
papule had a small, black eschar at the center. There was no
associated pain. The skin lesion was treated initially with 0.5%
hydrocortisone cream with some symptomatic improvement, and then
a 7 day empiric course of Valtrex given concern for shingles.
The lesions resolved over the course of ~ 10 days.

# Right heart failure:
The patient presented with significant weight gain and lower
extremity edema to the knees, with evidence of right heart
failure on TTE, likely secondary to pulmonary hypertension. She
also had evidence of left-sided diastolic failure with pulmonary
edema, likely from impaired LV filling in the setting of RV
overload. She was diuresed aggressively with increasing Lasix
dose to a maximum of 80 mg IV tid, with average output of
roughly 2 L / day for the space of two weeks, and then a single
dose of Metolazone. At this point, she had a contraction
alkalosis with Cr bump to 1.1 (from 0.5-0.6 baseline). She
diuresed to a dry weight of 79.9 kg (173 lbs), which is 8 kg
from her admission weight, and 16 kg from her max recorded
weight during this admission (may be some discrepancy in
scales). She says that at home (before gaining weight), her dry
weight was between 185-190 lbs. Symptomatically, she was much
improved, and her O2 sat improved as described above.  Dry
weight on discharge was 81.1 kg.

# Pulmonary HTN:
Pulmonary was consulted and recommended right heart
catheterization and pulmonary function tests were recommended as
an outpatient.

# Mediastinal lymphadenopathy - Her mediastinal biopsy showed
only non-specific proliferative changes. Pulmonary recommended
that she follow up with them as an outpatient.

#CAD s/p stents: She was continued on home clopidogrel and ASA.

#DM: She was treated with SSI while in house.

#HLD: She was continued on her home statin.

#HTN: As discussed above her antihypertensives were held during
her hypotensive episodes.

TRANSITIONAL ISSUES:
- consider decreasing aspirin dose from full strength to baby
aspirin 81mg daily in setting of being on both cilastazol and
clopidogrel
- recheck LFTs and chemistries in [**4-3**] days
- consider MRCP in setting of transient LFT elevations
- consider PFTs
- consider Right Heart Cath


Medications on Admission:
1. ALENDRONATE 70 mg weds - (pt does not taking this medication)
2. CILOSTAZOL 100 mg [**Hospital1 **]
3. CLOPIDOGREL 75 mg qd
4. GLYBURIDE 5 qd
5. LISINOPRIL 20 qd
6. METFORMIN 1,000 [**Hospital1 **]
7. METOPROLOL SUCCINATE [TOPROL XL] 200 qd
8. NIACIN 500 [**Hospital1 **]
9. OMEPRAZOLE 20 qd
10. PREGABALIN 100 [**Hospital1 **]
11. SIMVASTATIN 40 qd


Discharge Medications:
1. Home Oxygen
O2 via nasal cannula 2 Liters
Dx: CAD/pulmonary hypertension
Sats: low 80s on room air today
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day.

4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

6. niacin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
10. pregabalin 100 mg Capsule Sig: One (1) Capsule PO twice a
day.
11. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
13. Outpatient Lab Work
Please follow up with Primary Care Physician and get blood drawn
on [**2178-10-1**] to get the following labs drawn:
Chem 10
AST, ALT, Alk Phos, T Bili


Discharge Disposition:
Home With Service

Facility:
Home Care [**Location (un) 511**]

Discharge Diagnosis:
Primary:
- Pulmonary hypertension
- Congestive heart failure

Secondary:
- Atrial flutter


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital for a procedure to sample
lymph nodes in your chest. After the procedure, you had very low
blood pressure and a difficult time breathing. You had to be
treated in the intensive care unit for an abnormal heart rhythm.
You were then transferred to the regular medicine service, where
you received medication to help remove fluid and to control your
heart rate. You lost more than 25 lbs of fluid weight and your
breathing greatly improved. Your liver function tests were found
to be slightly increased, we would recommend following up with
your primary care physician for an [**Name9 (PRE) 60478**].

Changes made to your medications:
- Please STOP Lisinopril 20 mg for now until your primary care
physician feels it is safe to restart
- Please DECREASE Metoprolol Succinate to 100mg daily
- Please START torsemide 20mg daily
- Please STOP lasix

Please ask your cardiologist whether or not you may decrease
your aspirin full strength to the baby aspirin dose (81mg)
daily.

Please follow up with your primary care physician later this
week. Please be sure to follow up your liver function tests and
kidney function with him and consider getting an MRCP.

You will also need to get Pulmonary Function Tests and follow up
with your cardiologist for a potential Right Heart
Catheterization.

Followup Instructions:
* Please be sure to call your primary care doctor's office when
you go home to set up an appointment with him in the next [**4-3**]
days to recheck your labs*

Name: [**Last Name (LF) **],[**First Name3 (LF) **] A
Location: [**Location (un) **] FAMILY PRACTICE
Address: [**Location (un) 66508**], [**Location (un) **],[**Numeric Identifier 28669**]
Phone: [**Telephone/Fax (1) 41186**]

Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
Appointment: Wednesday [**2178-10-7**] 11:15am
{'Enlargement of lymph nodes,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Primary pulmonary hypertension,Acidosis,Acute kidney failure, unspecified,Atrial flutter,Other iatrogenic hypotension,Hypercalcemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery'}


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: A.Fib RVR, hemodynamically unstable s/p mediastinoscopy

PRESENT ILLNESS: 62 year old female with history of HTN, CAD s/p DES to LCx/LAD
in [**10/2177**], severe PAH, biventricular diastolic dysfunction, and
mediastinal lymphadenopathy electively admitted to thoracic
surgery s/p mediastinoscopy yesterday with persistent hypoxia
and lactic acidosis.
.
Right and left heart cath in [**10/2177**] showed pulmonary artery
pressures of 67/23/46. Nuclear stress last month showed
uninterpretable ECG for ischemia due to abnormal baseline, with
appropriate hemodynamic response to Persantine. No anginal type
symptoms, a fixed mild decrease in septal activity may be
related to LBBB. Normal LV wall motion and systolic function,
with hyperdynamic LVEF of 85%.
.
During this admission, she was noted to have an oxygen
saturation of 90% in pre-op and was hypotensive during the case,
to the 60s systolic, and required ephedrine and neo to maintain
her BPs. Bronchoscopy showed clear secretions. In the PACU she
was extubated and continued to have low O2 sats 88-90% on 3
liters N/C, although both the patient and her daughter explained
that this is her baseline and she does not use home oxygen. She
reported taking her home lisinopril and atenolol the morning of
the mediastinoscopy. She did not take her Lasix. She was also
unable to void in the PACU and when a foley was placed she
urinated 200cc. Her urine output in PACU reached a low of 17
cc/hour but averaged 20-30 cc/hour overnight. She had an initial
VBG that was 7.29/35/26 and a lactate of 5. On repeat VBG four
hours later it was 7.30/34/43 and lactate was 5 again. She was
transferred to Medicine for management of her lactic acidosis
and hypoxia.

MEDICAL HISTORY: Past Medical History:
DM
CAD s/p LAD cypher stenting
occult SBE with aortiv valve vegetation
severe pHTN
HTN
HLD
.
Past Sx History:
Rt Fem-[**Doctor Last Name **] bypass
Rt CEA following CVA prior to [**2173**]
Lt CEA following TIA [**2173**]
Stenting of LCx DPromus [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] of Prox/Mid LAD with Promus Stent

MEDICATION ON ADMISSION: 1. ALENDRONATE 70 mg weds - (pt does not taking this medication)
2. CILOSTAZOL 100 mg [**Hospital1 **]
3. CLOPIDOGREL 75 mg qd
4. GLYBURIDE 5 qd
5. LISINOPRIL 20 qd
6. METFORMIN 1,000 [**Hospital1 **]
7. METOPROLOL SUCCINATE [TOPROL XL] 200 qd
8. NIACIN 500 [**Hospital1 **]
9. OMEPRAZOLE 20 qd
10. PREGABALIN 100 [**Hospital1 **]
11. SIMVASTATIN 40 qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 98.3 BP: 108/91 (rechecked at 7 AM 89/61) P:158
(rechecked 134) R: 24 on NRB (19 on BiPAP) O2:  96% on 50% o2
General: Alert, oriented, on NRB
HEENT: Sclera slightly icteric, MMM, oropharynx clear
Neck: Mediastonsocpy site near jugular notch appears CDI. JVP
elevated to below jaw line at 75 degrees.
Lungs: Coarse rhonchi/crackles in lower lung fields bilaterally
left worse than right.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis 1+
edema
surgical scars consistent with revascularization procedures.
.
Discharge Physical Exam:

FAMILY HISTORY: Father had MI in his 50's and stroke in his 60's.  Siblings with
DM.

SOCIAL HISTORY: Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies 

### Response:
{'Enlargement of lymph nodes,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Primary pulmonary hypertension,Acidosis,Acute kidney failure, unspecified,Atrial flutter,Other iatrogenic hypotension,Hypercalcemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery'}
