CHIEF COMPLAINT: Edema, dyspnea

PRESENT ILLNESS: 57 yo male with afib, venous insufficiency, significant UGIB,
who presents to Dr.[**Name (NI) 5452**] office today with c/o worsening
dyspnea and increasing weight gain and edema. He denies
orthopnea or PND. He was told to have a sleep study, but he has
not had that. He states he has alot of medical problems, but
none of them are to the point where it concerns him. He denies
any back or neck pain. He's had venous insufficiency and ulcers
associated with that for a while, followed by Dr. [**Last Name (STitle) **]
of vascular for that. In Dr.[**Name (NI) 5452**] clinic, an echo was performed
which showed e/o right heart strain and ? cor pulmonale. He was
referred to our ED for further eval.

MEDICAL HISTORY: 1. Atrial fibrillation not anticoagulated since significant GIB
2. History of alcohol abuse.
3. Hypertension.
4. Upper gastrointestinal bleed in [**2167-7-7**] secondary to
prepyloric ulcer.
5. Psoriasis.
6. Mitral valve prolapse.
7. Gastric biopsy in [**2163-2-7**] showing esophagitis and
gastritis, H-pylori negative.
8. The patient had repeat esophagogastroduodenoscopy in
[**2167-10-7**] showing evidence of gastritis, however, a
healed prepyloric ulcer.
9. Adrenal insuffiency diagnosed in [**2172**] and on hydrocortizone
replacement therapy.

MEDICATION ON ADMISSION: Protonix 40 mg [**Hospital1 **]
Vitamin C 500 mg daily
Lasix 100 mg daily
Hydrocortisone 10 mg daily
Digoxin 250 mcg daily
Hydroxyzine 25 mg 1-2 tabs [**Hospital1 **]
Ferrous Sulfate 325 daily
Folic acid 1 mg daily
Metoprolol 100 mg daily

ALLERGIES: Sulfasalazine / Warfarin / Vancomycin

PHYSICAL EXAM: VS:98 120/81 58 22 95% 4L
GENERAL: obese male, NAD. had "ruddy" look. sleeping, but
arousable and answers questions appropriately.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
ruddy appearance of face
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
decreased BS bilateral bases, few bibasilar crackles. no rhonci

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient currently works part time as a spanish teacher at
middle school. He has smoked a half a pack per day of tobacco
times 30 years.  He reports occasional alcohol use, but has a
history of alcohol abuse in the past. He denies any other drug
use.
Acute on chronic diastolic heart failure,Acute respiratory failure,Acidosis,Cellulitis and abscess of leg, except foot,Ulcer of other part of lower limb,Bacteremia,Glucocorticoid deficiency,Chronic airway obstruction, not elsewhere classified,Diseases of tricuspid valve,Cirrhosis of liver without mention of alcohol,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Venous (peripheral) insufficiency, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mitral valve disorders,Lichenification and lichen simplex chronicus,Other respiratory abnormalities,Obesity, unspecified,Atrial fibrillation,Polycythemia, secondary,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Long-term (current) use of steroids
Ac on chr diast hrt fail,Acute respiratry failure,Acidosis,Cellulitis of leg,Ulcer oth part low limb,Bacteremia,Glucocorticoid deficient,Chr airway obstruct NEC,Tricuspid valve disease,Cirrhosis of liver NOS,Chr pulmon heart dis NEC,Obstructive sleep apnea,Tobacco use disorder,Venous insufficiency NOS,Mth sus Stph aur els/NOS,Mitral valve disorder,Lichenification,Respiratory abnorm NEC,Obesity NOS,Atrial fibrillation,Secondary polycythemia,Hypertension NOS,Depressive disorder NEC,Long-term use steroids
Admission Date:  [**2173-3-24**]              Discharge Date:   [**2173-4-8**]

Date of Birth:  [**2115-8-1**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfasalazine / Warfarin / Vancomycin

Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Edema, dyspnea

Major Surgical or Invasive Procedure:
Right and left heart catherizations
PICC placement [**2173-4-7**]


History of Present Illness:
57 yo male with afib, venous insufficiency, significant UGIB,
who presents to Dr.[**Name (NI) 5452**] office today with c/o worsening
dyspnea and increasing weight gain and edema. He denies
orthopnea or PND. He was told to have a sleep study, but he has
not had that. He states he has alot of medical problems, but
none of them are to the point where it concerns him. He denies
any back or neck pain. He's had venous insufficiency and ulcers
associated with that for a while, followed by Dr. [**Last Name (STitle) **]
of vascular for that. In Dr.[**Name (NI) 5452**] clinic, an echo was performed
which showed e/o right heart strain and ? cor pulmonale. He was
referred to our ED for further eval.

In ED, initial vitals were 61, 112/85, mid 80s on RA, and then
increased to 95% on 4L. He was noted to have bilateral crackles
and anasarca on exam. A CTA was performed which was negative for
PE. The patient was then admitted for volume overload. He was
not given lasix in the ED in case a cath was to be performed in
the AM.
ECG was afib without any ischemic changes. cardiac enzymes were
not very remarkable.

On floor, patient was comfortable. he denied chest pain or SOB.
he confirmed above.

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

Past Medical History:
1. Atrial fibrillation not anticoagulated since significant GIB
2. History of alcohol abuse.
3. Hypertension.
4. Upper gastrointestinal bleed in [**2167-7-7**] secondary to
prepyloric ulcer.
5. Psoriasis.
6. Mitral valve prolapse.
7. Gastric biopsy in [**2163-2-7**] showing esophagitis and
gastritis, H-pylori negative.
8. The patient had repeat esophagogastroduodenoscopy in
[**2167-10-7**] showing evidence of gastritis, however, a
healed prepyloric ulcer.
9. Adrenal insuffiency diagnosed in [**2172**] and on hydrocortizone
replacement therapy.


Social History:
The patient currently works part time as a spanish teacher at
middle school. He has smoked a half a pack per day of tobacco
times 30 years.  He reports occasional alcohol use, but has a
history of alcohol abuse in the past. He denies any other drug
use.


Family History:
Noncontributory

Physical Exam:
VS:98 120/81 58 22 95% 4L
GENERAL: obese male, NAD. had "ruddy" look. sleeping, but
arousable and answers questions appropriately.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
ruddy appearance of face
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
decreased BS bilateral bases, few bibasilar crackles. no rhonci

ABDOMEN: obses, soft tissue edema; large stretch marks
throughout abdomen. reddish color. normal bowel sounds
EXTREMITIES: dark feet, erythematous legs, bandaged. 3+ edema
bilatearlly up through thighs
SKIN: stasis dermaitits and ulcers present; bandage in place
PULSES:
Right: Carotid 2+ unable to appreciate femoral pulse [**2-8**] body
habitus. 1+ DP pulse
Left: Carotid 2+ unable to appreciate femoral pulse [**2-8**] body
habitus. 1+ DP pulse


Pertinent Results:
Admission Labs:
[**2173-3-24**] 05:30PM   CK-MB-NotDone
[**2173-3-24**] 05:30PM   cTropnT-0.06*
[**2173-3-24**] 05:30PM   ALT(SGPT)-15 AST(SGOT)-35 LD(LDH)-382*
CK(CPK)-45 ALK PHOS-188* TOT BILI-3.0* DIR BILI-1.6* INDIR
BIL-1.4
[**2173-3-24**] 07:50PM   PT-17.4* PTT-32.2 INR(PT)-1.6*
.
CTA [**2173-3-24**]:
1. No evidence of pulmonary embolus or aortic dissection.
2. Nodular shrunken hepatic contour, could reflect chronic
passive congestion and/or liver disease. clinical correlation is
advised.
3. Unchanged left hepatic lobe hypoattenuation, could reflect a
simple cyst.
4. Bilateral pleural effusions, anasarca and ascites, in the
setting of cor pulmonale is probably secondary to right heart
failure.
.
Arterial Doppler [**2173-3-25**]:
Doppler evaluation was performed of both lower extremity
arterial systems at rest. On the right, Doppler tracings are
triphasic at the femoral, popliteal and dorsalis pedis. They are
absent at the posterior tibial. Ankle brachial index is 1.08.
Pulse volume recordings are mildly decreased at the ankle and
metatarsal. Left Doppler tracings are triphasic at the femoral,
popliteal, and posterior tibial levels. They are monophasic at
the dorsalis pedis.  Ankle brachial index is 0.94. Pulse volume
recordings show mild drop off at the ankle and metatarsal.
IMPRESSION: Mild bilateral tibial artery occlusive disease.
.
Abdominal utlrasound [**2173-3-25**]:
1. Very heterogeneous liver with no solid liver mass identified.

2. Hyperdynamic pulsatile bidirectional flow seen in all of the
portal veins.
Large hepatic vein. These findings suggest tricuspid
insufficiency.
3. Sludge in the gallbladder.
4. Small amount of ascites.
.
Cardiac echo [**2173-3-26**]:
This study was compared to the prior study of [**2170-10-9**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. The IVC is
dilated (>2.5cm)
LEFT VENTRICLE: Mild symmetric LVH. Mildly dilated LV cavity.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%). No resting
LVOT gradient. No VSD.
RIGHT VENTRICLE: Dilated RV cavity. RV function depressed.
Abnormal diastolic septal motion/position consistent with RV
volume overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Aortic valve not well seen.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Moderate [2+] TR. Moderate PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
CONCLUSIONS:
Suboptimal image quality. Images insufficient to exclude an ASD
or PFO.The left atrium is moderately dilated. The right atrium
is markedly dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is mildly dilated. Due
to suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). There is no ventricular septal
defect. The right ventricular cavity is dilated with depressed
free wall contractility. There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve is not well seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Suboptimal image quality. Agitated saline
could not be seen in the right atrium after injection.

[**2173-3-30**] PFTS:
SPIROMETRY 8:00 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred %chg
FVC   1.54 4.55 34 1.67 37 +9
FEV1   1.01 3.26 31 1.07 33 +6
MMF   0.47 3.19 15 0.44 14 -7
FEV1/FVC   66 72 92 64 90 -2

LUNG VOLUMES 8:00 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   2.99 6.81 44
FRC   1.81 3.82 47
RV   1.59 2.26 70
VC   1.41 4.55 31
IC   1.18 2.99 40
ERV   0.22 1.56 14
RV/TLC   53 33 160
He Mix Time   4.75
.
DLCO 8:00 AM
    Actual Pred %Pred
DSB   11.46 27.09 42
VA(sb)   2.21 6.81 32
HB   17.70
DSB(HB)   10.64 27.09 39
DL/VA   4.81 3.98 121
.
CCath [**2173-3-30**]:
cath - left clean, right elevated pressures, severe pHTN, did
not respond to nitric oxide
.
Right Foot XRay:
IMPRESSION: Degenerative changes primarly involving the great
toe. No
findings to suggest bone destruction
.
Discharge Labs:
.
140 / 96 / 18 / 107
3.8 / 36 / 0.9

Ca: 9.0 Mg: 2.0 P: 2.6

WBC 6.6 Plt 247
Hct 48.6

PT: 16.1  PTT: 34.9  INR: 1.4
.
ABG [**2173-4-8**]: pH 7.38 pCO2 62 pO2 78 HCO3 38 BaseXS 8

Brief Hospital Course:
Mr. [**Known lastname 21914**] is a 57 yo M with afib, p/w severe R CHF and volume
overload as well as c/b BLE venous stasis breakdown. R CHF [**2-8**]
cor pulmonae from OSA and pulmonary edema and anasarca on lasix
ggt and on BiPAP at night.
.
Since admission, aggressive diuresis has been pursued. [**3-25**]
began diuresis with IV lasix. Abdominal u/s was obtained to
evaluate for cirrhosis given distended abdomen and elevated INR
and revealed a hetergenous liver. Wound care recs obtained.
Pulmonary consult [**3-26**] thought exam / studies consistent with
pulmonary HTN, obtained PFTs, [**Location (un) **]/lung volumes/DLCO & obtain
HIV, [**Doctor First Name **], ds-DNA, anti-CSL, RF, ESR, CRP. Sleep evaluation
recommended supplemental O2, avoid empiric CPAP (both CPAP and
autotitrate BiPAP with desaturation). He was also being followed
by PT. [**3-27**] Sprinolactone and K were added. Dermatology consult
[**3-29**] for pruritic rash though c/w prurigo nodularis and
recommended anti-histamines, clobetasol [**Hospital1 **], d/c neosporin,
bactroban [**Hospital1 **] to open lesions, if persittent could consider
cryothearpy or IL sterioids, f/up in 3 months. For his stasis
recommneded compression of entire foot and knee if can tolerate,
elevation, Unna boots. Trigger [**3-30**] for spreading rash and
somnolence, given Fenofexadine, on supplemental O2. Trigger [**3-31**]
for hypoxia and altered mental status, pt O2 to 70s on CPAP at
10L with patient difficult to arouse. Pulmonary [**3-31**]
reccommended keeping upright, continue lasix and consider adding
Diamoxx, nebs PRN, try auto-BiPAP. On [**4-2**] recommended d/c
Spironolactone and continuing diuresis. Cardiology attending was
recommending screening for rehab while continuing Lasix gtt.
[**4-3**] patient triggered for difficulty with arousing, was
cultured and ABG was sent revealing pH 7.38, pCO2 69, pO2 66,
HCO3 42, lactate 1.1. Repeat ABG pH 7.37, pCO2 68, pO2 66, HCO3
41. Patient remained somnolent with some concern for hypotension
and bradycardia. He was then transferred to the ICU for further
evaluation of these complaints.
.
MICU Course: Patient stabilized clinically on BiPAP.  Sleep
recommended a special ASV machine.  We continued aggressive
diuresis with lasix 120mg PO BID with good effect.  He grew [**2-10**]
MSSA from his blood for which he was placed on nafcillin after a
brief course of daptomycin (has vanco allergy).  A PICC was
placed [**2173-4-7**].  He will need a 2 week course of nafcillin
through [**2173-4-17**].  Vascular changed his LE dressings.  He will
need follow up with vascular and dermatology.  We restarted his
metoprolol with good effect.
.
By Problem:
.
57 yo M with afib, admitted with CHF exacerbation [**2-8**] cor
[**Hospital 21915**] transferred to ICU for AMS likely multifactorial [**2-8**]
pulmonary edema, OSA and GPC bacteremia [**2-8**] chronic RLE ulcer.
.
MSSA Bacteremia/RLE ULCER: Most likely source at this time was
RLE ulcer, vascular was consulted.  Foot xray without concern
for infection.  He was empirically on daptomycin then switched
to nafcillin.  PICC was placed [**2173-4-7**].  His surveillance
cultures remained NGTD except for 1 culture with coag neg staph
was thought to be contaminant.  Echo was negative for
vegetation.  he will need 2 weeks of antibiotics through
[**2173-4-17**].
.
Obstructive Sleep Apnea:  Patient was seen by pulmonary and
vasculitis labs sent. During R heart cath, patient had severe
pHTN and no improvement with nitric oxide. Sleep study not
tolerated because patient could not tolerate CPAP mask. PFTs
were reflective of restrictive physiology from obesity.  He was
put on ASV machine and tolerated well.  He will need to wear
this at night and follow up in sleep clinic.  He will need a
sleep study prior to that appointment.
.
Hypoxia/Hypercarbia: - Likely multifactorial including some
pulmonary edema (as evidenced on CXR), pulmonary hypertension
and cor pulmonale.  no e/o PE on CTA from admission.  He is
mildly hypercarbic at baseline.  He responded well to the above
interventions and to lasix.
.
Right heart failure - Secondary to cor pulmonae from COPD/OSA.
No significant evidence of alcoholic cardiomyopathy. Echo showed
normal EF, not major LV dysfunction and showed significant pHTN
and TR. No improvement with nitric oxide, thus did not start
sildenafil or CCB. Patient s/p right and left heart cath. No
evidence of ASD. Left heart cath negative for CAD.  We resumed
his lasix at 120mg PO BID with very good effect.  We re-started
his metoprolol with good effect.  His lasix will need to be
adjusted prn given his volume status, though he likely remains
total body fluid overloaded on discharge.
.
Atrial Fibrillation: Currently not anticoagluated [**2-8**] massive
GIB while on coumadin and Ciprofloxacin.  Rate controlled with
metoprolol.  No ASA due to h/o GIB.
.
Prurigo nodularis: Dermatology saw patient who recommended
applying creams and to follow up with dermatology in 3 months.
Continue atarax QHS, clobetasol 0.05% ointment [**Hospital1 **], capsaicin
cream TID x 4 weeks, mupirocin Cream 2% 1 Appl TP [**Hospital1 **] to open
lesions/excoriations
.
Venous insuffiency/RLE Ulcer:  Status post Apligraf placement on
his right leg on [**1-14**]. Arterial flow studies, good flow until
tibia.  Chronic issue.  Foot xray without evidence of infection.
 Continued dressings and will need follow up with vascular
surgery.
.
Depression ?????? started on citalopram 10mg daily.  Can uptitrate as
needed
.
Access: PICC was placed successfully on [**2173-4-7**]

Medications on Admission:
Protonix 40 mg [**Hospital1 **]
Vitamin C 500 mg daily
Lasix 100 mg daily
Hydrocortisone 10 mg daily
Digoxin 250 mcg daily
Hydroxyzine 25 mg 1-2 tabs [**Hospital1 **]
Ferrous Sulfate 325 daily
Folic acid 1 mg daily
Metoprolol 100 mg daily

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Hydrocortisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed.
15. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
16. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3
times a day).
18. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
19. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
20. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
21. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): adjusted prn based on fluid status.
22. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
23. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
24. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1)
injection Intravenous Q4H (every 4 hours): through [**2173-4-17**] for
14 day course after negative cultures.
25. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary Diagnosis:
Hypercarbic respiratory failure
Obesity Hypoventilation Syndrome
Obstructive Sleep Apnea
Pulmonary Hypertension
Congestive Heart Failure
Bacteremia: Methicillin Sensitive Staph Aureus
.
Secondary Diagnoses:
Atrial Fibrillation
Venous insufficiency
Hypertension
Adrenal Insufficiency


Discharge Condition:
Good, mentating well, hemodynamically stable, oxygenating well


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liters
.
The patient was admitted with multifactorial shortness of breath
most likely caused by congestive heart failure and fluid
overload, obstructive sleep apnea, and pulmonary hypertension.
He was initially aggressively diuresed with a lasix drip on
cardiology.  However, he was transferred to the MICU due to
persistent somnolence.  While in the ICU his ASV was adjusted
with the help of pulmonology with good effect.  He was also
diuresed aggressively.  He will be discharged to continue his
ASV mask and to follow up in sleep clinic.  He will also need
continued diuresis.
.
He was also followed by vascular surgery for his lower extremity
venous insufficiency as well as rash.  He will need to follow up
with vascular surgery as well as dermatology to track his rash.
.
He was also diagnosed with MSSA bacteremia, for which he will
need 2 weeks of IV Nafcillin and periodic liver and kidney
monitoring
.
He should also follow up with his cardiologist and PCP as soon
as possible.
.
Please continue all of his medications as prescribed and adjust
his lasix based on his volume status.  Please have patient
return to the hospital if his shortness of breath worsens, he
experiences chest pain, somnolence or any other concerning
symptoms

Followup Instructions:
Vascular Surgery:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2173-4-14**] 1:45
.
Sleep Clinic/Pulmonology:
Provider: [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2173-4-22**] 11:00
.
Endocrinology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2173-5-24**] 1:30
.
the patient will need an outpatient sleep study prior to his
appointment with Dr. [**Last Name (STitle) 4507**].
.
The patient should follow up with Dermatology in the next 3
months to re-evaluate his rash
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Acidosis,Cellulitis and abscess of leg, except foot,Ulcer of other part of lower limb,Bacteremia,Glucocorticoid deficiency,Chronic airway obstruction, not elsewhere classified,Diseases of tricuspid valve,Cirrhosis of liver without mention of alcohol,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Venous (peripheral) insufficiency, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mitral valve disorders,Lichenification and lichen simplex chronicus,Other respiratory abnormalities,Obesity, unspecified,Atrial fibrillation,Polycythemia, secondary,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Long-term (current) use of steroids'}


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: Edema, dyspnea

PRESENT ILLNESS: 57 yo male with afib, venous insufficiency, significant UGIB,
who presents to Dr.[**Name (NI) 5452**] office today with c/o worsening
dyspnea and increasing weight gain and edema. He denies
orthopnea or PND. He was told to have a sleep study, but he has
not had that. He states he has alot of medical problems, but
none of them are to the point where it concerns him. He denies
any back or neck pain. He's had venous insufficiency and ulcers
associated with that for a while, followed by Dr. [**Last Name (STitle) **]
of vascular for that. In Dr.[**Name (NI) 5452**] clinic, an echo was performed
which showed e/o right heart strain and ? cor pulmonale. He was
referred to our ED for further eval.

MEDICAL HISTORY: 1. Atrial fibrillation not anticoagulated since significant GIB
2. History of alcohol abuse.
3. Hypertension.
4. Upper gastrointestinal bleed in [**2167-7-7**] secondary to
prepyloric ulcer.
5. Psoriasis.
6. Mitral valve prolapse.
7. Gastric biopsy in [**2163-2-7**] showing esophagitis and
gastritis, H-pylori negative.
8. The patient had repeat esophagogastroduodenoscopy in
[**2167-10-7**] showing evidence of gastritis, however, a
healed prepyloric ulcer.
9. Adrenal insuffiency diagnosed in [**2172**] and on hydrocortizone
replacement therapy.

MEDICATION ON ADMISSION: Protonix 40 mg [**Hospital1 **]
Vitamin C 500 mg daily
Lasix 100 mg daily
Hydrocortisone 10 mg daily
Digoxin 250 mcg daily
Hydroxyzine 25 mg 1-2 tabs [**Hospital1 **]
Ferrous Sulfate 325 daily
Folic acid 1 mg daily
Metoprolol 100 mg daily

ALLERGIES: Sulfasalazine / Warfarin / Vancomycin

PHYSICAL EXAM: VS:98 120/81 58 22 95% 4L
GENERAL: obese male, NAD. had "ruddy" look. sleeping, but
arousable and answers questions appropriately.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
ruddy appearance of face
NECK: Supple with JVP of 12 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. irregularly irregular, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
decreased BS bilateral bases, few bibasilar crackles. no rhonci

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient currently works part time as a spanish teacher at
middle school. He has smoked a half a pack per day of tobacco
times 30 years.  He reports occasional alcohol use, but has a
history of alcohol abuse in the past. He denies any other drug
use. 

### Response:
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Acidosis,Cellulitis and abscess of leg, except foot,Ulcer of other part of lower limb,Bacteremia,Glucocorticoid deficiency,Chronic airway obstruction, not elsewhere classified,Diseases of tricuspid valve,Cirrhosis of liver without mention of alcohol,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Venous (peripheral) insufficiency, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Mitral valve disorders,Lichenification and lichen simplex chronicus,Other respiratory abnormalities,Obesity, unspecified,Atrial fibrillation,Polycythemia, secondary,Unspecified essential hypertension,Depressive disorder, not elsewhere classified,Long-term (current) use of steroids'}
