CHIEF COMPLAINT: Shortness of breath, nausea

PRESENT ILLNESS: Mr. [**Known lastname 14966**] is a 60-year-old man with history of severe dilated
cardiomyopathy (EF 10-15%, non-ischemic, likely familial) status
post ICD implantation with a biventricular upgrade in [**12/2145**],
amiodarone induced pneumonitis, multiple DVTs, chronic atrial
fibrillation,HTN, HLD, DM2, who was recently discharged from
[**Hospital1 18**] [**2146-12-13**] for ICD firing/V.Fib, and after attempting
several anti-arrhythmics, was eventually discharged on
quinidine. Seroquel was discontinued at that time due to its
arrythmogenic potential.
.
He developed constant dyspnea soon after discharge (about 10
days ago) occurring at rest and limiting his mobility to just a
few steps. This was accompanied by 2-pillow orthopnea and
frequent nightly episodes of PND limiting sleep. He notes
consistent compliance with all his meds, including his
diuretics, and denies dietary indiscretions. His appetite was
rather limited, in actuality. He is on chronic home 02 at 2L,
which he increased to 3L He has had multiple admissions in the
past few years for CHF exacerbation, and notes that his current
symptoms feel similar.
.
He also endorses consistent nausea over the past 10 days which
had been progressive, limiting his appetite, and resulting in
[**1-29**] daily episodes of dry-heaving. His symptoms seem to have
improved within the past 2-3 days, corresponding to a decreased
dose of quinidine.
.
While he denies chest pain, he does endorse a several year
history of intermittent chest pressure, occuring once a month.
The sensation is substernally localized with a [**Doctor Last Name **] sign,
though dissipates within 20 seconds, and is unrelated to
exertion. It does not radiate, and is unacompanied by
diaphoresis, anxiety, or dyspnea. He is currently chest
pain-free.
.
He has a history of multiple PE and DVT, but denies calf
tenderness, pleuritic chest pain, palpitations, or lower
extremity edema.
.
In the ED, his vital signs were 98 82 130/81 100% on 2L. His
examination was significant for a lack of JVD, crackles, or
lower extremity edema. His CXR demonstrated no congestion,
though a BNP was elevated at 6655. EKG demonstrated only Afib,
ventricular paced with PVCs. BP was running low in the upper
90's after giving anti-hypertensives that were missed that
morning.
.
On arrival to the floor, his vital signs were T=100.3 BP= 97/55
HR= 81 RR= 22 O2 sat= 97%2L.  He was comfortable in NAD.
Complaining only of some mild lower back pain.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
.
On general review of symptoms, he denies any prior history of
stroke, TIA, current myalgias, joint pains, cough, sputum,
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.
.

MEDICAL HISTORY: Cardiac Risk Factors:
+Diabetes (from steroids for pneumonitis), +Dyslipidemia,
+Hypertension
.
Cardiac History:
-history of an acute myocardial infarction due to a small
embolic event in [**5-/2145**]
-Percutaneous coronary intervention, in [**2145-6-11**] anatomy as
follows: two vessel coronary artery disease. The LMCA was a
large vessel with no angiographically apparent disease. The LAD
was a large vessel with apical diffuse narrowing and an abrupt
termination. The Lcx had a 90% stenosis in the mid to distal
LPDA with probable filling defect. The RCA was small without any
angiographically apparent disease.
.
Pacemaker/ICD, in [**2141**] for primary prevention, upgrade to BiV
[**2145**]
.
Other Past History:
- Dyslipidemia
- Hypertension
- dilated cardiomyopathy, severely depressed EF (10-15%), s/p
ICD [**2141**] for primary prevention
- Afib
- polymorphic VT after dofetilide
- Amiodarone-induced hypersensitivity pneumonitis
- Diabetes, diagnosed after being on steroids for pneumonitis
- GI bleed on Coumadin [**2137**] possibly related to ischemic colitis
- OSA, not on CPAP
- multiple previous DVTs including DVT and PE in [**2126**] following
an ankle trauma, and second episode of PE in [**2137**]. IVC filter
placed [**2137**]. Also had a right brachial vein DVT in [**2139**].
.
PAST SURGICAL HISTORY
- lap cholecystectomy [**2-/2144**]
- IVC filter placement [**2137**]
- bilateral cataract surgery with residual right ptosis

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, PO DAILY (Daily).
2. captopril 25 mg Tablet [**Hospital1 **]
3. cholecalciferol (vitamin D3) 1000mg QD
4. quinidine gluconate 324 mg Tablet Sustained Release PO Q8H
5. escitalopram 10 mg Tablet PO DAILY
6. fondaparinux 7.5 mg/0.6 mL daily
7. furosemide 100mg PO BID
8. multivitamin QD
9. methylprednisolone 5mg PO DAILY
10. metoprolol tartrate 200mg [**Hospital1 **]
11. mirtazapine 15mg Qhs
12. omeprazole 20 mg Capsule, 40mg [**Hospital1 **]
13. simvastatin 40 mg Tablet daily
14. spironolactone 12.5 mg QD
15. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for back pain.
16. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:

ALLERGIES: Amiodarone / Nifedipine / Fentanyl / Ambien

PHYSICAL EXAM: VS: T=100.3 BP= 97/55 HR= 81 RR= 22 O2 sat= 97%2L  Wt 91.1kg
GENERAL: Patient is a fatigued-appearing gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MM were dry.
NECK: Supple with JVP to the jaw. No carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, rate normal, normal S1, S2. 1/6 systolic
ejection murmur heard best at second right ICS. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Scattered crackles at
the bases but generally quite clear to auscultation.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No lower extremity edema palpated. 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+
.
DISCHARGE PHYSICAL EXAMINATION:
WEIGHT: 87.6Kg
HEENT:  JVP 10cm
PULM:  CTAB, no crackles
CARDS: normal exam

FAMILY HISTORY: There is family history of premature coronary artery disease in
patient's father, who had first MI at age 37. He had several
heart attacks, the second occuring in his 40s. Mother also has
dilated cardiomyopathy. Sister had ?[**Name2 (NI) 41267**] CMY (1 episode of
heart failure when very emotional and sad)

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
 use. Quit smoking 7 years ago after smoking for 40 years x
2ppd.  He drinks no etoh. Lives with wife. Worked at chemical
plant making latex.
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis,Old myocardial infarction,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Personal history of venous thrombosis and embolism,Long-term (current) use of insulin,Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of tobacco use,Nausea alone,Other iatrogenic hypotension
Ac on chr syst hrt fail,Acute kidney failure NOS,Prim cardiomyopathy NEC,Sec DM wo cmp nt st uncn,Atrial fibrillation,Status autm crd dfbrltr,Hypertension NOS,Postinflam pulm fibrosis,Old myocardial infarct,Obstructive sleep apnea,Hyperlipidemia NEC/NOS,Hx-ven thrombosis/embols,Long-term use of insulin,Adv eff corticosteroids,History of tobacco use,Nausea alone,Iatrogenc hypotnsion NEC
Admission Date:  [**2146-12-22**]              Discharge Date:   [**2146-12-27**]

Date of Birth:  [**2086-7-2**]             Sex:   M

Service: MEDICINE

Allergies:
Amiodarone / Nifedipine / Fentanyl / Ambien

Attending:[**First Name3 (LF) 4071**]
Chief Complaint:
Shortness of breath, nausea

Major Surgical or Invasive Procedure:
right heart catheterization [**2146-12-23**]

History of Present Illness:
Mr. [**Known lastname 14966**] is a 60-year-old man with history of severe dilated
cardiomyopathy (EF 10-15%, non-ischemic, likely familial) status
post ICD implantation with a biventricular upgrade in [**12/2145**],
amiodarone induced pneumonitis, multiple DVTs, chronic atrial
fibrillation,HTN, HLD, DM2, who was recently discharged from
[**Hospital1 18**] [**2146-12-13**] for ICD firing/V.Fib, and after attempting
several anti-arrhythmics, was eventually discharged on
quinidine. Seroquel was discontinued at that time due to its
arrythmogenic potential.
.
He developed constant dyspnea soon after discharge (about 10
days ago) occurring at rest and limiting his mobility to just a
few steps. This was accompanied by 2-pillow orthopnea and
frequent nightly episodes of PND limiting sleep. He notes
consistent compliance with all his meds, including his
diuretics, and denies dietary indiscretions. His appetite was
rather limited, in actuality. He is on chronic home 02 at 2L,
which he increased to 3L He has had multiple admissions in the
past few years for CHF exacerbation, and notes that his current
symptoms feel similar.
.
He also endorses consistent nausea over the past 10 days which
had been progressive, limiting his appetite, and resulting in
[**1-29**] daily episodes of dry-heaving. His symptoms seem to have
improved within the past 2-3 days, corresponding to a decreased
dose of quinidine.
.
While he denies chest pain, he does endorse a several year
history of intermittent chest pressure, occuring once a month.
The sensation is substernally localized with a [**Doctor Last Name **] sign,
though dissipates within 20 seconds, and is unrelated to
exertion. It does not radiate, and is unacompanied by
diaphoresis, anxiety, or dyspnea. He is currently chest
pain-free.
.
He has a history of multiple PE and DVT, but denies calf
tenderness, pleuritic chest pain, palpitations, or lower
extremity edema.
.
In the ED, his vital signs were 98 82 130/81 100% on 2L. His
examination was significant for a lack of JVD, crackles, or
lower extremity edema. His CXR demonstrated no congestion,
though a BNP was elevated at 6655. EKG demonstrated only Afib,
ventricular paced with PVCs. BP was running low in the upper
90's after giving anti-hypertensives that were missed that
morning.
.
On arrival to the floor, his vital signs were T=100.3 BP= 97/55
HR= 81 RR= 22 O2 sat= 97%2L.  He was comfortable in NAD.
Complaining only of some mild lower back pain.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
.
On general review of symptoms, he denies any prior history of
stroke, TIA, current myalgias, joint pains, cough, sputum,
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:
Cardiac Risk Factors:
+Diabetes (from steroids for pneumonitis), +Dyslipidemia,
+Hypertension
.
Cardiac History:
-history of an acute myocardial infarction due to a small
embolic event in [**5-/2145**]
-Percutaneous coronary intervention, in [**2145-6-11**] anatomy as
follows: two vessel coronary artery disease. The LMCA was a
large vessel with no angiographically apparent disease. The LAD
was a large vessel with apical diffuse narrowing and an abrupt
termination. The Lcx had a 90% stenosis in the mid to distal
LPDA with probable filling defect. The RCA was small without any
angiographically apparent disease.
.
Pacemaker/ICD, in [**2141**] for primary prevention, upgrade to BiV
[**2145**]
.
Other Past History:
- Dyslipidemia
- Hypertension
- dilated cardiomyopathy, severely depressed EF (10-15%), s/p
ICD [**2141**] for primary prevention
- Afib
- polymorphic VT after dofetilide
- Amiodarone-induced hypersensitivity pneumonitis
- Diabetes, diagnosed after being on steroids for pneumonitis
- GI bleed on Coumadin [**2137**] possibly related to ischemic colitis
- OSA, not on CPAP
- multiple previous DVTs including DVT and PE in [**2126**] following
an ankle trauma, and second episode of PE in [**2137**]. IVC filter
placed [**2137**]. Also had a right brachial vein DVT in [**2139**].
.
PAST SURGICAL HISTORY
- lap cholecystectomy [**2-/2144**]
- IVC filter placement [**2137**]
- bilateral cataract surgery with residual right ptosis

Social History:
Social history is significant for the absence of current tobacco
 use. Quit smoking 7 years ago after smoking for 40 years x
2ppd.  He drinks no etoh. Lives with wife. Worked at chemical
plant making latex.


Family History:
There is family history of premature coronary artery disease in
patient's father, who had first MI at age 37. He had several
heart attacks, the second occuring in his 40s. Mother also has
dilated cardiomyopathy. Sister had ?[**Name2 (NI) 41267**] CMY (1 episode of
heart failure when very emotional and sad)

Physical Exam:
VS: T=100.3 BP= 97/55 HR= 81 RR= 22 O2 sat= 97%2L  Wt 91.1kg
GENERAL: Patient is a fatigued-appearing gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MM were dry.
NECK: Supple with JVP to the jaw. No carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, rate normal, normal S1, S2. 1/6 systolic
ejection murmur heard best at second right ICS. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Scattered crackles at
the bases but generally quite clear to auscultation.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No lower extremity edema palpated. 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+
.
DISCHARGE PHYSICAL EXAMINATION:
WEIGHT: 87.6Kg
HEENT:  JVP 10cm
PULM:  CTAB, no crackles
CARDS: normal exam


Pertinent Results:
ADMISSION LABS:
.
[**2146-12-22**] 11:46AM   PT-20.7* PTT-25.5 INR(PT)-1.9*
[**2146-12-22**] 11:46AM   PLT COUNT-204
[**2146-12-22**] 11:46AM   NEUTS-84.6* LYMPHS-7.5* MONOS-5.7 EOS-0.5
BASOS-1.7
[**2146-12-22**] 11:46AM   WBC-6.6 RBC-5.20 HGB-15.1 HCT-46.0 MCV-89
MCH-29.0 MCHC-32.7 RDW-18.4*
[**2146-12-22**] 11:46AM   proBNP-6655*
[**2146-12-22**] 11:46AM   ALT(SGPT)-56* AST(SGOT)-40 LD(LDH)-436* ALK
PHOS-79 TOT BILI-1.7* DIR BILI-0.8* INDIR BIL-0.9
[**2146-12-22**] 11:46AM   estGFR-Using this
[**2146-12-22**] 11:46AM   GLUCOSE-118* UREA N-27* CREAT-1.1 SODIUM-135
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18
[**2146-12-22**] 11:57AM   LACTATE-3.3*
[**2146-12-22**] 11:57AM   TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2146-12-22**] 01:50PM   LACTATE-2.3*
.
DISCHARGE LABS:
[**2146-12-27**] 07:10AM BLOOD WBC-7.3 RBC-5.54 Hgb-15.9 Hct-49.0 MCV-89
MCH-28.6 MCHC-32.4 RDW-18.1* Plt Ct-188
[**2146-12-27**] 07:10AM BLOOD Glucose-99 UreaN-26* Creat-1.0 Na-139
K-3.8 Cl-99 HCO3-32 AnGap-12
.
CARDIOLOGY:
[**2146-12-22**] 11:46AM   cTropnT-<0.01
[**2146-12-22**] 09:05PM   cTropnT-<0.01
.
EKG: Ventricular paced rhythm at 83 BPM. Compared to the
previous tracing of [**2146-12-13**] no
definite change.
.
RIGHT CARDIAC CATHETERIZATION [**2146-12-23**]:
1. Limited resting hemodynamics revealed elevated left and right
heart filling pressures. The RVEDP was 16mmHg. The mean PCW was
31 in a tracing with come PA pressure artifact. The cardiac
output was 4.0L/min and cardiac index 2.0 L/min/m2 using the
Fick method assuming arterial oxygen saturation from peripheral
oximetry and mean arterial pressure from cuff pressures. The
oxygen consumption was assumed. The SVR was 1320 dynes*sec/cm5
and PVR 180 dynes*sec/cm5. FINAL DIAGNOSIS:    1. Low output
congestive heart failure with elevated filling pressures.
.
IMAGING STUDIES:
.
CXR [**2146-12-22**]:  Again seen is a left-sided pacer defibrillator
with leads ending in the expected location of the right and left
ventricle, unchanged. Lung volumes are normal. The lungs are
clear
bilaterally with no areas of focal consolidation. There is no
pleural effusion or pneumothorax. Cardiomegaly remains stable.
IMPRESSION: No acute intrathoracic process. Stable cardiomegaly.


Brief Hospital Course:
Mr. [**Known lastname 14966**] is a pleasant 60 year old man with h/o severe
non-ischemic cardiomyopathy with EF 10-15% s/p BiV ICD,
amiodarone-induced pneumonitis, coagulopathy with multiple
DVT/PE, chronic AF s/p ablation, HTN, DM2, HLD who presents with
progressive dyspnea and elevated PWP seen on right heart cath
consistent with worsening heart failure:
.
ACUTE ISSUES:
.
1.  Acute on Chronic systolic heart failure:  The patient
presented with progressive dyspnea since his last
hospitalization with an elevated BNP, though he appeared
relatively euvolemic on exam, only demonstrating anelevated JVP.
His CXR was clear.  For further characterization of his cardiac
performance, he underwent right sided cardiac catheterization on
[**2146-12-23**] which demonstrated an elevated PCWP and depressed
cardiac index consistent with worsening heart failure.  As he is
in late-stage HF, a swan [**Doctor Last Name **] catheter was placed in the right
IJ and he was transferred to the CCU post procedure for more
aggressive diuresis.  He was begun on a lasix gtt and was
diuresed to a wedge pressure of 18 with significant improvement
of his symptoms. The gtt was stoppped secondary to hypotension
to 70s which resolved, though his pressures remained in the
mid-90s to low 100s for the rest of his hospitalization.  He was
then transferred to the floor on [**12-25**] for optimization of his
HF regimen.  He was transitioned to PO torsemide and maintained
adequate diuresis.  He was started on lisinopril and digoxin,
and his beta blocker was transitioned to toprol XL.  His
spironolactone was increased to 25mg QD. He was seen by Dr.
[**First Name (STitle) 437**] of the HF team and will follow up with him as an
outpatient.  He was without SOB on discharge and achieved a dry
weight of 87.5 Kg.
.
2.  Arrhythmia:  He has A fib, with BiV/ICD in place.  He
remained V-paced at 70-80s with intermittent PVCs. His quinidine
was stopped secondary to nausea, and he experienced a 20 beat
run of VT on [**12-25**].  He was asymptomatic and his ICD did not
fire. He was started on mexilitine and experienced one further
10 beat run VT prior to D/C. He will f/u with Dr. [**Last Name (STitle) 1911**]
as an outpatient.
.
3. Nausea:  he presented with 10 days of nausea and dry-heaves,
which improved following a dose decrease in his quinidine.  The
quinidine was eventually stopped in the CCU with resolution of
his symptoms.
.
4. [**Last Name (un) **]: His creatinine is elevated from 0.8-1.1 on admission.
Due to his symptoms of overload, he may have experienced
decreased cardiac output from dilation.  His Cr imrpoved
slightly to 1.0 following diuresis.
.
INACTIVE ISSUES:

5.  Coagulopathy: He has a history of multiple PE/DVT in the
past and is s/p IVC filter in [**2137**].  His fundaparinux was held
on the day of admission in anticipation of right-heart cath the
following morning but was restarted post-procedure.
.
6.  DM2- He has steroid-driven DM2 and was continued on glargine
and ISS with satisfactory FSG.
.
7.  HTN:BP was running somewhat low with SBP 90s-100s, which is
apparently at his baseline.
.
8.  HLD: continued zocor

TRANSITIONAL ISSUES: none

Medications on Admission:
1. aspirin 81 mg Tablet, PO DAILY (Daily).
2. captopril 25 mg Tablet [**Hospital1 **]
3. cholecalciferol (vitamin D3) 1000mg QD
4. quinidine gluconate 324 mg Tablet Sustained Release PO Q8H
5. escitalopram 10 mg Tablet PO DAILY
6. fondaparinux 7.5 mg/0.6 mL daily
7. furosemide 100mg PO BID
8. multivitamin QD
9. methylprednisolone 5mg PO DAILY
10. metoprolol tartrate 200mg [**Hospital1 **]
11. mirtazapine 15mg Qhs
12. omeprazole 20 mg Capsule, 40mg [**Hospital1 **]
13. simvastatin 40 mg Tablet daily
14. spironolactone 12.5 mg QD
15. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for back pain.
16. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:

One (1) ML Inhalation every 4 hours () as needed for SOB,
wheezing.
17. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) Units

Subcutaneous once a day.
18. senna 8.6 mg Tablet [**Hospital1 **] PRN constipation
19. docusate sodium 100 mg Capsule [**Hospital1 **]


Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous DAILY (Daily).
6. torsemide 100 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*5*
7. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
8. methylprednisolone 2 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
9. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*5*
10. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.

11. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO twice a day.
12. Zocor 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
15. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4hours PRN () as needed for SOB.
16. insulin glargine 100 unit/mL Cartridge Sig: Eight (8) units
Subcutaneous at bedtime.
17. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
21. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*5*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Services

Discharge Diagnosis:
1.  Acute on chronic systolic heart failure exacerbation
2.  Nausea/vomiting secondary to quinidine
3.  Atrial fibrillation s/p BiV ICD with intermittent
self-terminating V-tach


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


Discharge Instructions:
Dear Mr. [**Known lastname 14966**],

You were admitted to the hospital with shortness of breath that
was likely caused by an exacerbation of your congestive heart
failure.  You underwent a catheterization procedure to establish
this diagnosis, and you spent a few days in the cardiac ICU to
remove some excess fluid from your body with lasix.  You were
then transferred back to the regular cardiology floor, where we
optimized your medications and finished diuresing you.  Your
breathing improved greatly by the time of discharge.

You also experienced nausea and vomiting prior to your admission
and in the hospital.  We suspect this was triggered by the
quinidine, so this was stopped.  You were started on a new drug
to control your heart rhythm, called mexilitine.

The following changes were made to your medications:
1. STOP LASIX
2. START TORSEMIDE, a new diuretic which is absorbed more evenly
3. START MEXILITINE to help control your heart rhythm
4. STOP QUINIDINE, as it probably caused nausea and vomiting
5. START LISINOPRIL instead of captopril to protect your heart
6. STOP CAPTOPRIL
7. INCREASE SPIRONOLACTONE to 25mg daily
8. START TOPROL XL 100mg daily to protect your heart
9. STOP METOPROLOL TARTRATE
10. START DIGOXIN 0.125mcg daily to help your heart contract
harder

Please continue all other medications as prescribed by your
other doctors.

As always, please remember to weigh yourself daily, and call
your doctor if your weight increases more than 3 pounds.


Followup Instructions:
Your PCP has been notified of your admission and will call you
at home with an appointment to be seen soon.

You have an appointment to see Dr. [**Last Name (STitle) 1911**] in [**Location (un) **] to
treat your heart rhythm.
Department: CVI [**Location (un) **], [**Apartment Address(1) **]
When: MONDAY [**2147-1-9**] at 11:20 AM
With: [**Last Name (un) 1918**] [**Doctor Last Name **] [**Telephone/Fax (1) 11767**]
Building: [**Location (un) 20588**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

You have the following appointment to meet with Dr. [**First Name (STitle) 437**] of our
heart failure team to manage your CHF.
Department: CARDIAC SERVICES
When: MONDAY [**2147-1-30**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4074**]
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis,Old myocardial infarction,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Personal history of venous thrombosis and embolism,Long-term (current) use of insulin,Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of tobacco use,Nausea alone,Other iatrogenic hypotension'}


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, nausea

PRESENT ILLNESS: Mr. [**Known lastname 14966**] is a 60-year-old man with history of severe dilated
cardiomyopathy (EF 10-15%, non-ischemic, likely familial) status
post ICD implantation with a biventricular upgrade in [**12/2145**],
amiodarone induced pneumonitis, multiple DVTs, chronic atrial
fibrillation,HTN, HLD, DM2, who was recently discharged from
[**Hospital1 18**] [**2146-12-13**] for ICD firing/V.Fib, and after attempting
several anti-arrhythmics, was eventually discharged on
quinidine. Seroquel was discontinued at that time due to its
arrythmogenic potential.
.
He developed constant dyspnea soon after discharge (about 10
days ago) occurring at rest and limiting his mobility to just a
few steps. This was accompanied by 2-pillow orthopnea and
frequent nightly episodes of PND limiting sleep. He notes
consistent compliance with all his meds, including his
diuretics, and denies dietary indiscretions. His appetite was
rather limited, in actuality. He is on chronic home 02 at 2L,
which he increased to 3L He has had multiple admissions in the
past few years for CHF exacerbation, and notes that his current
symptoms feel similar.
.
He also endorses consistent nausea over the past 10 days which
had been progressive, limiting his appetite, and resulting in
[**1-29**] daily episodes of dry-heaving. His symptoms seem to have
improved within the past 2-3 days, corresponding to a decreased
dose of quinidine.
.
While he denies chest pain, he does endorse a several year
history of intermittent chest pressure, occuring once a month.
The sensation is substernally localized with a [**Doctor Last Name **] sign,
though dissipates within 20 seconds, and is unrelated to
exertion. It does not radiate, and is unacompanied by
diaphoresis, anxiety, or dyspnea. He is currently chest
pain-free.
.
He has a history of multiple PE and DVT, but denies calf
tenderness, pleuritic chest pain, palpitations, or lower
extremity edema.
.
In the ED, his vital signs were 98 82 130/81 100% on 2L. His
examination was significant for a lack of JVD, crackles, or
lower extremity edema. His CXR demonstrated no congestion,
though a BNP was elevated at 6655. EKG demonstrated only Afib,
ventricular paced with PVCs. BP was running low in the upper
90's after giving anti-hypertensives that were missed that
morning.
.
On arrival to the floor, his vital signs were T=100.3 BP= 97/55
HR= 81 RR= 22 O2 sat= 97%2L.  He was comfortable in NAD.
Complaining only of some mild lower back pain.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.
.
On general review of symptoms, he denies any prior history of
stroke, TIA, current myalgias, joint pains, cough, sputum,
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.
.

MEDICAL HISTORY: Cardiac Risk Factors:
+Diabetes (from steroids for pneumonitis), +Dyslipidemia,
+Hypertension
.
Cardiac History:
-history of an acute myocardial infarction due to a small
embolic event in [**5-/2145**]
-Percutaneous coronary intervention, in [**2145-6-11**] anatomy as
follows: two vessel coronary artery disease. The LMCA was a
large vessel with no angiographically apparent disease. The LAD
was a large vessel with apical diffuse narrowing and an abrupt
termination. The Lcx had a 90% stenosis in the mid to distal
LPDA with probable filling defect. The RCA was small without any
angiographically apparent disease.
.
Pacemaker/ICD, in [**2141**] for primary prevention, upgrade to BiV
[**2145**]
.
Other Past History:
- Dyslipidemia
- Hypertension
- dilated cardiomyopathy, severely depressed EF (10-15%), s/p
ICD [**2141**] for primary prevention
- Afib
- polymorphic VT after dofetilide
- Amiodarone-induced hypersensitivity pneumonitis
- Diabetes, diagnosed after being on steroids for pneumonitis
- GI bleed on Coumadin [**2137**] possibly related to ischemic colitis
- OSA, not on CPAP
- multiple previous DVTs including DVT and PE in [**2126**] following
an ankle trauma, and second episode of PE in [**2137**]. IVC filter
placed [**2137**]. Also had a right brachial vein DVT in [**2139**].
.
PAST SURGICAL HISTORY
- lap cholecystectomy [**2-/2144**]
- IVC filter placement [**2137**]
- bilateral cataract surgery with residual right ptosis

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, PO DAILY (Daily).
2. captopril 25 mg Tablet [**Hospital1 **]
3. cholecalciferol (vitamin D3) 1000mg QD
4. quinidine gluconate 324 mg Tablet Sustained Release PO Q8H
5. escitalopram 10 mg Tablet PO DAILY
6. fondaparinux 7.5 mg/0.6 mL daily
7. furosemide 100mg PO BID
8. multivitamin QD
9. methylprednisolone 5mg PO DAILY
10. metoprolol tartrate 200mg [**Hospital1 **]
11. mirtazapine 15mg Qhs
12. omeprazole 20 mg Capsule, 40mg [**Hospital1 **]
13. simvastatin 40 mg Tablet daily
14. spironolactone 12.5 mg QD
15. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4H (every 4 hours) as needed for back pain.
16. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:

ALLERGIES: Amiodarone / Nifedipine / Fentanyl / Ambien

PHYSICAL EXAM: VS: T=100.3 BP= 97/55 HR= 81 RR= 22 O2 sat= 97%2L  Wt 91.1kg
GENERAL: Patient is a fatigued-appearing gentleman in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MM were dry.
NECK: Supple with JVP to the jaw. No carotid bruits.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregular rhythm, rate normal, normal S1, S2. 1/6 systolic
ejection murmur heard best at second right ICS. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Scattered crackles at
the bases but generally quite clear to auscultation.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No lower extremity edema palpated. 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+
.
DISCHARGE PHYSICAL EXAMINATION:
WEIGHT: 87.6Kg
HEENT:  JVP 10cm
PULM:  CTAB, no crackles
CARDS: normal exam

FAMILY HISTORY: There is family history of premature coronary artery disease in
patient's father, who had first MI at age 37. He had several
heart attacks, the second occuring in his 40s. Mother also has
dilated cardiomyopathy. Sister had ?[**Name2 (NI) 41267**] CMY (1 episode of
heart failure when very emotional and sad)

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
 use. Quit smoking 7 years ago after smoking for 40 years x
2ppd.  He drinks no etoh. Lives with wife. Worked at chemical
plant making latex. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Unspecified essential hypertension,Postinflammatory pulmonary fibrosis,Old myocardial infarction,Obstructive sleep apnea (adult)(pediatric),Other and unspecified hyperlipidemia,Personal history of venous thrombosis and embolism,Long-term (current) use of insulin,Adrenal cortical steroids causing adverse effects in therapeutic use,Personal history of tobacco use,Nausea alone,Other iatrogenic hypotension'}
