CHIEF COMPLAINT: Weight gain.

PRESENT ILLNESS: 63 y/o M w/ h/o CHF now transferred for decompensated heart
failure and inotropic assisted diuresis. By report from OSH
patient patient had a 15 lb weight gain prior to admission with
increased dyspnea and non-productive cough. Outpatient
physicians attempted to increase her diuretics but were unable
to successfully mitigate her weight gain. As such she presented
to OSH on [**2144-4-7**].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension

MEDICATION ON ADMISSION: MEDICATIONS on transfer:
-Lasix 100mg IV BID
-Coreg 3.125 [**Hospital1 **]
-Cipro 250 [**Hospital1 **]
-Digoxin 125 daily
-Zocor 20mg
-Potassium 20 [**Hospital1 **]
-Protonix 40mg daily
-Levothyroxine 50ucg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Mother alive at 90 with h/o HTN. Father died of MI. Has two
brothers with no apparent health problems.

SOCIAL HISTORY: Nursing home resident.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Nutritional marasmus,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Bacteremia,Paroxysmal ventricular tachycardia,Acute apical periodontitis of pulpal origin,Malignant neoplasm of middle third of esophagus,Hypotension, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Barrett's esophagus
Ac on chr syst hrt fail,Acute respiratry failure,Pneumonia, organism NOS,Nutritional marasmus,Gastrointest hemorr NOS,Ac posthemorrhag anemia,Delirium d/t other cond,Bacteremia,Parox ventric tachycard,Ac apical periodontitis,Mal neo middle 3rd esoph,Hypotension NOS,MRSA elsewhere/NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Barrett's esophagus
Admission Date:  [**2144-4-11**]              Discharge Date:   [**2144-5-13**]

Date of Birth:  [**2081-1-14**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Weight gain.

Major Surgical or Invasive Procedure:
Endotracheal intubation [**2144-4-13**]
Left radial artery catheter placement [**2144-4-11**]
Right radial artery catheter placement [**2144-4-16**]
Left radial artery catheter placement [**2144-4-27**]
Right heart catheterization [**2144-4-14**]
Right internal jugular central venous catheter [**2144-4-11**]
Left internal jugaular central venous catheter placement [**2144-4-15**]
EGD [**2144-4-20**]
Push enteroscopy [**2144-5-4**]
EGD with endoscopic ultrasound [**2144-5-6**]
Dental extractions [**2144-4-27**]
Dobhoff nasogastric tube placement [**2144-4-30**]
PICC placement [**2144-5-11**]

History of Present Illness:
63 y/o M w/ h/o CHF now transferred for decompensated heart
failure and inotropic assisted diuresis. By report from OSH
patient patient had a 15 lb weight gain prior to admission with
increased dyspnea and non-productive cough. Outpatient
physicians attempted to increase her diuretics but were unable
to successfully mitigate her weight gain. As such she presented
to OSH on [**2144-4-7**].

Initial impression was for systolic CHF and patient was given
lasix IV. Pressures dropped to 90s with lasix, however. By
report her ECG was NSR with RBBB morphology and no significant
ST/T wave changes. At the OSH, cardiology consultation
recommended a dose reduction in her carvedilol and initiated low
dose ACE. Consideration was given to ICU transfer for dopamine
assisted diuresis, but consultation with CHF service lead to
referral to [**Hospital1 18**] for milrinone assisted diuresis.

Patient is poor historian. Reports dyspnea with minimal exertion
for some time, and increasing edema. Endorses PND/orthopnea at
home. Denies fevers/chills sick contacts, recent travel or other
new complaints.

On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, hemoptysis, black stools
or red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

On arrival, initial VS were: T95, BP 70/47, HR 52, RR 20, O2 98%
5L NC

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension

2. CARDIAC HISTORY:
-CHF with EF 15%
-CABG: none.
-PERCUTANEOUS CORONARY INTERVENTIONS:
- Cath with CTO of proximal LAD.
-PACING/ICD: Has PPM in place.

3. OTHER PAST MEDICAL HISTORY:
-Hypertension
-Anemia
-Metabolic Encephalopathy
-Hypothyroidism
-Stage III CKD
-MRSA
-s/p permanent pacemaker

Social History:
Nursing home resident.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies

Family History:
Mother alive at 90 with h/o HTN. Father died of MI. Has two
brothers with no apparent health problems.

Physical Exam:
GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
LABS:

Admission labs:
[**2144-4-11**] 06:34PM BLOOD WBC-9.9 RBC-4.04* Hgb-9.6* Hct-31.8*
MCV-79* MCH-23.6* MCHC-30.0* RDW-17.5* Plt Ct-171
[**2144-4-11**] 06:34PM BLOOD Neuts-91.4* Lymphs-3.7* Monos-4.5 Eos-0.2
Baso-0.1
[**2144-4-11**] 06:34PM BLOOD PT-14.5* PTT-33.7 INR(PT)-1.3*
[**2144-4-11**] 06:34PM BLOOD Glucose-118* UreaN-49* Creat-1.4* Na-130*
K-4.6 Cl-97 HCO3-25 AnGap-13
[**2144-4-11**] 06:34PM BLOOD ALT-23 AST-22 LD(LDH)-279* CK(CPK)-29
AlkPhos-271* TotBili-1.0
[**2144-4-11**] 06:34PM BLOOD CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier **]*
[**2144-4-11**] 06:34PM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.2 Mg-2.3
[**2144-4-11**] 06:34PM BLOOD Ferritn-189*
[**2144-4-12**] 06:15AM BLOOD %HbA1c-6.6* eAG-143*
[**2144-4-11**] 06:34PM BLOOD Digoxin-1.0
[**2144-4-11**] 11:48PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2144-4-11**] 11:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2144-4-11**] 11:48PM URINE RBC-1 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1

MICROBIOLOGY:

CSF gram stain and culture [**2144-5-4**]: No growth

Mandibular [**Month/Day/Year 500**] [**2144-4-27**]:
[**Female First Name (un) **] ALBICANS(SPARSE GROWTH)
                     ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

Sputum culture [**2144-4-13**]: STAPH AUREUS COAG +
                             |          PROTEUS MIRABILIS
                          |          |
AMPICILLIN------------              <=2 S
AMPICILLIN/SULBACTAM--              <=2 S
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------              <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------              =>4 R
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S      <=1 S
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------           <=0.25 S
OXACILLIN-------------   =>4 R
PIPERACILLIN/TAZO-----              <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S     =>16 R
VANCOMYCIN------------ <=0.5 S

Blood culture [**2144-4-12**]: STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     2 S

IMAGING:

Echocardiogram, transthoracic [**2144-4-13**]: The left atrium is mildly
dilated. Left ventricular wall thicknesses and cavity size are
normal. There is mild to moderate regional left ventricular
systolic dysfunction with near akinesis of the distal third of
the ventricle with an aneurysmal apex. There is mild hypokinesis
of the remaining segments (LVEF = 30 %). No masses or thrombi
are seen in the left ventricle. The right ventricular cavity is
markedly dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild [1+] mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with apical
anerysm and near akinesis of the distal left ventricle. Markedly
dilated right ventricle with free wall hypokinesis. Mild mitral
regurgitation.

Echocardiogram, transesophageal [**2144-4-17**]: No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**2-15**]+) mitral regurgitation is seen. No masses
or vegetations are seen on the tricuspid valve. No
vegetation/mass is seen on the pulmonic valve. No
vegetation/mass is seen on the RV/RA wires.There is no
pericardial effusion. IMPRESSION: No vegetations on valves or
RV/RA wires. Mild to moderate mitral regurgitation.

Echocardiogram, transthoracic [**2144-5-4**]: The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed (LVEF= 20-25 %) with
global hypokinesis and regional akinesis to dyskinesis of the
distal LV and apex. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Moderate (2+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion. Compared with the prior study
(images reviewed) of [**2144-4-13**], the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] detected
has increased.

CT head w/o contrast [**2144-4-14**]:
1. No acute intracranial hemorrhage or mass effect.
2. Extensive paranasal sinus disease as described above, with
air-fluid levels and aerosolized secretions in the maxillary
sinuses, indicating an acute competent.
3. Diffuse osteopenia, with some altered attenuation, to
correlate with hematology labs.
4. Incidental findings of [**Last Name (un) 2432**] cisterna magna along with mildly
dilated ventricles, which might relate to volume loss with or
without superimposed component of communicating hydrocephalus
suggest normal pressure hydrocephalus. To correlate clinically.
5. Small radiolucent focus noted in the left frontal [**Last Name (un) 500**], which
may represent a hemangioma or focal lytic lesion. Correlation
with MR [**First Name (Titles) **] [**Last Name (Titles) 500**] scan can be considered if there is history of an
underlying primary malignancy. Otherwise, a followup study can
be considered to assess stability/progression, given the lack of
prior images

GI bleeding study [**2144-5-1**]: GI bleeding likely within the
proximal small bowel present within first 15 minutes.

CTA Abdomen/Pelvis [**2144-5-2**]:
1. No active extravasation identified. Patent mesenteric
arteries. The site of bleeding identified on the GI scan is not
identified.
2. Large bilateral pleural effusions.
3. Cholelithiasis.
4. Anasarca.
5. The right hepatic artery arises from the SMA. The SMA may
also supply the left hepatic artery and therefore the common
hepatic artery.

ENDOSCOPY:

EGD [**2144-4-20**]:
Small hiatal hernia
Salmon-colored mucosa consistent with Barrett's esophagus note
at the GE junction. A band-like protruding lesion noted in the
area of Barrett's, more like mass than varices in the esophagus
Erythema, congestion and small erosions in the antrum compatible
with gastritis
Otherwise normal EGD to third part of the duodenum
.
Small bowel enteroscopy [**2144-5-4**]:
Mass in the lower third of the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum and jejunum upto 120 cm
Otherwise normal EGD to 120 cm

EGD/endoscopic ultrasound [**2144-5-6**]:
Mass in the middle third of the esophagus (biopsy)
EUS T stage: An exophytic esophageal mass involving the mucosa,
submucosa. This was staged as T 1 by EUS criteria.
No varices were noted.
N stage: No abnormal lymph nodes were noted. This was staged N0.

Staging applies if malignancy is confirmed.
Otherwise normal EGD to third part of the duodenum
.
PATHOLOGY:
.
CSF [**2144-5-4**]: Negative for malignant cells.
.
Esophageal biopsy [**2144-5-6**]:
1. Adenocarcinoma, at least intramucosal, and arising in a
background of intestinal metaplasia, consistent with Barrett's
esophagus.
2.  No definite submucosal tissue present to further evaluate
for invasion.
.
NEUROLOGY:
.
EEG [**2144-5-5**]: This telemetry captured no pushbutton activations.
Routine sampling showed a diffusely slow and disorganized
background consisting of mostly theta and delta frequencies.
There were no areas of prominent focal slowing and there were no
epileptiform features. Overall, this background is suggestive of
a severe encephalopathy. Amongst the most common causes of
encephalopathy are metabolic disturbances, medications,
infection, and anoxia.

Brief Hospital Course:
# Acute on chronic systolic heart failure: The patient was
initially transferred from an outside hospital in the setting of
a recent 15-pound weight gain and increased dyspnea and cough.
At the outside hospital, treatment with furosemide dropped the
patient's blood pressure to the 90s, and it was felt that
inotropic support would be required for diuresis. Milrinone was
initiated, but this resulted in hypotension and
tachyarrhythmias, so it was stopped. Phenylephrine and
vasopression were added, and the patient was diuresed with a
Lasix drip. Between [**2144-4-13**] and [**2144-4-21**], the patient's fluid
balance was negative 12 liters. Between [**2144-4-21**] and [**2144-5-1**], the
patient reaccumulated fluid in the setting of blood transfusions
and fluid boluses for GI bleeding and low urine output. Between
[**2144-5-1**] and [**2144-5-10**], diuresis proceeded with IV Lasix without
any need for pressors or inotropic support. TTE showed EF
20-25%.

# Hypotension/pressor requirement: The patient had persistent
hypotension, requiring vasopressors between [**2144-4-13**] and [**2144-4-29**].
Phenylephrine was started first, then vasopressin was added. The
patient also briefly required norepinephrine. The patient's
hypotension was felt to be multifactorial, with contributing
factors including ventricular dysfunction, decompensated heart
failure, bacteremia, sedating medications, diuresis, and GI
bleeding. For the latter, the patient received blood
transfusions. With time the patient's hypotension resolved, and
by [**2144-4-29**], she was off of all pressors.

# Respiratory failure: The patient developed hypercarbic
respiratory failure, requiring intubation on [**2144-4-13**]. She
extubated on [**2144-4-21**] and reintubated from [**Date range (3) 86123**] in the
setting of dental extractions.

# Esophageal carcinoma: An esophageal mass was incidentally
noted on an EGD performed on [**2144-4-20**] as part of the patient's
work-up for GI bleeding. The mass was further evaluated with
endoscopic ultrasound and biopsied on [**2144-5-6**]. Pathology showed
esophageal carcinoma. Endoscopic ultrasound revealed invasion to
the submucosa (T1). No abnormal lymph nodes were noted on EUS.
The heme/onc service was consulted, and recommended palliative
care. PET/CT could be considered for further staging, but this
might not affect the patient's management.  ERCP was consulted
for possibility of endoscopic resection, but given the high risk
of complications (10%) and need for emergent surgery that the
patient would likely not tolerate, this was thought to pose more
risk than benefit to the patient.

# GI bleeding: The patient had guaiac-positive stools since
admission. Her hematocrit remained stable until [**2144-4-18**], when it
began to fall, reaching a nadir of 19.4 on [**2144-4-19**]. The patient
was transfused a total of 9 units PRBCs between [**2144-4-19**] and
[**2144-5-1**]. EGD was notable for an esophageal mass that proved to
be an adenocarcinoma but was not felt to be the source of the
bleeding. A GI bleeding study, done on [**2144-5-1**], was suggestive
of a proximal small source. However, enteroscopy, done on
[**2144-5-4**], did not identify a source of bleeding. It was therefore
thought to be coming from the adenocarcinoma.  The patient's
hematocrit stabilized. Of note, the initial Hct drop occurred in
the setting of a heparin drip, with was subsequently
discontinued.

# Dental extractions: The patient was noted to have very poor
dentition. There was a concern that the patient's mouth could be
a source of systemic infection. The patient underwent extraction
of 24 teeth on [**2144-4-27**]. The extraction was without
complications. Mandibular culture grew [**Female First Name (un) **] and
vancomycin-resistent enterococcus.

# Malnutrition: The patient was severely malnourished. On
admission, her albumin was 1.9. Enteral tube feeding was
initiated, but it was stopped because the patient pulled out her
feeding tube. The patient began to eat as her mental status
improved, but her PO intake was still poor. Consideration was
given to a PEG tube, but the patient's family decided against
this.

# MRSA Bacteremia: Blood culture [**2144-4-12**] was positive for MRSA.
The patient also had a sputum culture from [**2144-4-13**] that grew MRSA
and Proteus. The patient was treated with vancomycin, cefepime,
and flagyl. She has been afebrile since [**2144-4-22**].

# Altered Mental Status: The patient had persistently altered
mental status, with gradual improvement after extubation. This
was felt to be related to medications and the ICU environment,
although the patient's mental status remained significantly
altered even after many days off medications. The neurology
service was consulted. There was a question of normal pressure
hydrocephalus on head CT, but the neurology service did not feel
that the patient had NPH. LP was performed and was notable only
for minimally elevated protein. EEG did not show any
epileptiform activity.

# Atrial fibrillation: The patient had rapid atrial fibrillation
while on a milrinone drip. The milrinone drip was discontinued.

# Non-sustained ventricular tachycardia: The patient started
amiodarone on [**2144-4-18**] for NSVT. Her dose was decreased to 200 mg
TID on [**4-24**], and then to 200 mg [**Hospital1 **] on [**2144-5-13**].  She will need
to decrease this dose to 200 mg once a day in 2 weeks (on
[**2144-5-26**]) and remain on that dose indefinitely.

# Goals of care: A family meeting was held on [**2144-5-9**], and the
decision was made to make the patient DNR/DNI. A magnet was
placed over her ICD.  The family discussed with social work
their preference for Do Not Re-hospitalize and confirmed this
the day of discharge.

Medications on Admission:
MEDICATIONS on transfer:
-Lasix 100mg IV BID
-Coreg 3.125 [**Hospital1 **]
-Cipro 250 [**Hospital1 **]
-Digoxin 125 daily
-Zocor 20mg
-Potassium 20 [**Hospital1 **]
-Protonix 40mg daily
-Levothyroxine 50ucg daily

Medications at Home:
-Coreg 6.25mg [**Hospital1 **]
-Zocor 20mg daily
-KCL 20meq [**Hospital1 **]
-Lasix 120mg [**Hospital1 **]
-ASA 81mg daily
-Protonix daily
-Levothyroxine daily

Discharge Medications:
1. Patient has required 80 - 100 mEqs daily while on Lasix drip.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**2-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
8. Multivitamins with Minerals     Capsule [**Month/Day (2) **]: One (1) Tablet
PO DAILY (Daily).
9. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day
for 2 weeks: Change this to 200 mg daily after these two weeks.

10. Docusate Sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheezes.
12. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezes.
13. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: [**2-15**]  Injection
[**Hospital1 **] (2 times a day).
14. Acetaminophen 500 mg Tablet [**Hospital1 **]: Two (2) elixir PO Q8H
(every 8 hours) as needed for pain: Consider changing to
standing at the first of pain. .
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
17. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
18. Morphine Sulfate 1-2 mg IV Q4H:PRN pain
hold if sedated or rr<10
19. Lasix drip
Furosemide 1-20 mg/hr IV DRIP INFUSION
Titrate to 1-2L negative per day until euovolemic. Hold for
SBP<90.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Location (un) 701**]

Discharge Diagnosis:
Primary Diagoses:
1. Acute on chronic systolic heart failure
2. Hypotension
3. Hypercarbic respiratory failure
4. Esophageal cancer
5. Bleeding from the gastrointestinal tract
6. Acute blood loss anemia
7. Delirium


Discharge Condition:
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Mental Status: Confused - sometimes (limited by dysarthria)


Discharge Instructions:
You were admitted to the hospital for evaluation of weight gain.
You were treated for heart failure with diuretic medications.
Your hospital course was complicated by breathing problems which
required intubation. You also had bleeding from the
gastrointestinal tract, for which you received multiple blood
transfusions. A mass was found in your esophagus, and a biopsy
was performed, showing that you have esophageal cancer.

weight goes up more than 3 lbs.


Completed by:[**2144-5-13**]
{"Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Nutritional marasmus,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Bacteremia,Paroxysmal ventricular tachycardia,Acute apical periodontitis of pulpal origin,Malignant neoplasm of middle third of esophagus,Hypotension, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Barrett's esophagus"}


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: Weight gain.

PRESENT ILLNESS: 63 y/o M w/ h/o CHF now transferred for decompensated heart
failure and inotropic assisted diuresis. By report from OSH
patient patient had a 15 lb weight gain prior to admission with
increased dyspnea and non-productive cough. Outpatient
physicians attempted to increase her diuretics but were unable
to successfully mitigate her weight gain. As such she presented
to OSH on [**2144-4-7**].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, + Hypertension

MEDICATION ON ADMISSION: MEDICATIONS on transfer:
-Lasix 100mg IV BID
-Coreg 3.125 [**Hospital1 **]
-Cipro 250 [**Hospital1 **]
-Digoxin 125 daily
-Zocor 20mg
-Potassium 20 [**Hospital1 **]
-Protonix 40mg daily
-Levothyroxine 50ucg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GENERAL: WDWN ** in NAD. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Mother alive at 90 with h/o HTN. Father died of MI. Has two
brothers with no apparent health problems.

SOCIAL HISTORY: Nursing home resident.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies 

### Response:
{"Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Nutritional marasmus,Hemorrhage of gastrointestinal tract, unspecified,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Bacteremia,Paroxysmal ventricular tachycardia,Acute apical periodontitis of pulpal origin,Malignant neoplasm of middle third of esophagus,Hypotension, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Barrett's esophagus"}
