CHIEF COMPLAINT: Complete Heart Block & Ventricular Tachycardia

PRESENT ILLNESS: 64yo man w/ h/o multiple medical problems including [**Name (NI) 2320**], CAD,
HepC/ETOH cirrhosis & HCC s/p orthotopic liver tx ('[**57**]) on
prograf w/ post-transplant course complicated by renal
insufficiency, tracheostomy, chronic colonization/infections w/
mult resistant organisms who was transferred from [**Location (un) 745**]
[**Hospital 3714**] Hospital to [**Hospital1 18**] CCU for pacemaker/ICD placement.  Pt
initially presented to NWH on [**2159-10-13**] w/ & AV block in setting
of hyperkalemia.  Pt tx'd w/ RIJ temporary pacing wire at NWH,
during which he developed Ventricular Tachycardia.  Pt out of AV
block, and in sinus rhythm upon arrival at [**Hospital1 18**].

MEDICAL HISTORY: 1. Liver transfusion for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

MEDICATION ON ADMISSION: Prograf 1 mg [**Hospital1 **]
Bactrim DS one tablet per day
Keflex 500mg PO q6H
Diflucan 200mg PO daily
Prednisone 5mg PO daily
Norvasc 10 mg PO daily
Protonix 40mg PO daily
Olanzapine 2.5mg PO daily
zinc sulfate 220 mg po daily
sliding scale insulin PRN
Heparin 5000 units subcutaneously TID
Ativan 1mg PO q6H PRN
Motrin 600mg PO PRN
Hydromorphone 0.5-2mg IV q2H PRN
Artificial tears
Miconazole powder PRN

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: VS: T: 99.2 HR: 70 RR: 19 bp: 131/91 SpO2: 97% on ventilatory
mask 0.35 FIO2
Gen: A&O*4, appears mildly distressed
HEENT: PERRLA, EOMI, 2mm pupils
Neck: trach, pacemaker insertion site C/D/I
Heart: temp pacemaker set at HR 50/ 10mV, RRR
Lung: coarse rhonchi louder on LLL than RLL
Abd: soft, NT, ND
Ext: 0.5cm pustule on distal lateral LLE surrounded by 1 cm
erythematous border

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.
Streptococcal septicemia,Sepsis,Atrioventricular block, complete,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute respiratory failure,Diastolic heart failure, unspecified,Liver replaced by transplant,Chronic kidney disease, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hyperpotassemia,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Tracheostomy status,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified local infection of skin and subcutaneous tissue
Streptococcal septicemia,Sepsis,Atriovent block complete,React-oth vasc dev/graft,Acute respiratry failure,Diastolc hrt failure NOS,Liver transplant status,Chronic kidney dis NOS,Abn react-org transplant,Hyperpotassemia,Other staphylococcus,DMII wo cmp nt st uncntr,Long-term use of insulin,Tracheostomy status,Phlbts sprfc vn up extrm,Hy kid NOS w cr kid I-IV,Local skin infection NOS
Admission Date:  [**2160-10-13**]              Discharge Date:   [**2160-10-24**]

Date of Birth:  [**2096-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Nsaids / Rapamune

Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Complete Heart Block & Ventricular Tachycardia

Major Surgical or Invasive Procedure:
s/p temporary pacemaker line removal
s/p right PICC line placement (and removal)
s/p left PICC line placement ([**2160-10-22**])


History of Present Illness:
64yo man w/ h/o multiple medical problems including [**Name (NI) 2320**], CAD,
HepC/ETOH cirrhosis & HCC s/p orthotopic liver tx ('[**57**]) on
prograf w/ post-transplant course complicated by renal
insufficiency, tracheostomy, chronic colonization/infections w/
mult resistant organisms who was transferred from [**Location (un) 745**]
[**Hospital 3714**] Hospital to [**Hospital1 18**] CCU for pacemaker/ICD placement.  Pt
initially presented to NWH on [**2159-10-13**] w/ & AV block in setting
of hyperkalemia.  Pt tx'd w/ RIJ temporary pacing wire at NWH,
during which he developed Ventricular Tachycardia.  Pt out of AV
block, and in sinus rhythm upon arrival at [**Hospital1 18**].


Past Medical History:
1. Liver transfusion for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

Social History:
Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.


Family History:
Non-contributory

Physical Exam:
VS: T: 99.2 HR: 70 RR: 19 bp: 131/91 SpO2: 97% on ventilatory
mask 0.35 FIO2
Gen: A&O*4, appears mildly distressed
HEENT: PERRLA, EOMI, 2mm pupils
Neck: trach, pacemaker insertion site C/D/I
Heart: temp pacemaker set at HR 50/ 10mV, RRR
Lung: coarse rhonchi louder on LLL than RLL
Abd: soft, NT, ND
Ext: 0.5cm pustule on distal lateral LLE surrounded by 1 cm
erythematous border


Pertinent Results:
Admission labs:
[**2160-10-13**] 08:22PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2160-10-13**] 08:22PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-10-13**] 08:22PM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2160-10-13**] 08:21PM   GLUCOSE-272* UREA N-48* CREAT-2.0* SODIUM-143
POTASSIUM-4.7 CHLORIDE-101 TOTAL CO2-31 ANION GAP-16
[**2160-10-13**] 08:21PM   ALT(SGPT)-23 AST(SGOT)-20 ALK PHOS-106 TOT
BILI-0.2
[**2160-10-13**] 08:21PM   ALBUMIN-3.2* CALCIUM-8.8 PHOSPHATE-4.2
MAGNESIUM-1.7
[**2160-10-13**] 08:21PM   WBC-4.8 RBC-3.03* HGB-8.8* HCT-24.7* MCV-82
MCH-29.0 MCHC-35.5* RDW-15.7*
[**2160-10-13**] 08:21PM   PLT COUNT-175
[**2160-10-13**] 08:21PM   PT-12.5 PTT-25.8 INR(PT)-1.1
.
.
Discharge Labs:
[**2160-10-24**] 05:01AM BLOOD WBC-4.6 RBC-2.95* Hgb-8.5* Hct-23.8*
MCV-81* MCH-28.8 MCHC-35.7* RDW-16.4* Plt Ct-168
[**2160-10-24**] 05:01AM BLOOD Glucose-99 UreaN-34* Creat-1.9* Na-141
K-4.1 Cl-101 HCO3-32 AnGap-12
[**2160-10-22**] 08:20AM BLOOD ALT-86* AST-34 LD(LDH)-239 AlkPhos-511*
TotBili-0.3
[**2160-10-24**] 05:01AM BLOOD FK506-4.0*
.
.
CXR: [**2160-10-13**]
FINDINGS: A temporary pacemaker lead has been placed via a left
internal jugular approach and there is a defibrillator pad
overlying the lower right hemithorax. There is more marked
elevation of the left hemidiaphragm. The heart and mediastinal
contours are stable. The pulmonary vasculature is normal. The
pleural spaces are normal and the lungs are clear, with the left
costophrenic angle excluded from the radiograph.
IMPRESSION: Elevated left hemidiaphragm, with no evidence of
acute cardiopulmonary process.
.
Echocardiogram: [**2160-10-14**]
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Compared with the
prior study (images reviewed) of [**2158-8-15**] , estimated pulmonary
artery pressure is now lower.
.
TEE [**2160-10-20**]:
Conclusions:
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the aortic arch. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
paravalvular
abcess.
.
ABD u/s:
INDICATION: Liver transplant with LFT abnormalities.
LIVER DOPPLER: The right common, middle, and left hepatic veins
appear patent with appropriate directionality of flow. The main
hepatic artery is patent. The portal veins are patent with
hepatopetal flow. Incidental note is made of a small cyst in the
right lobe of the liver. There is no evidence of biliary ductal
dilatation.
IMPRESSION: Patent hepatic vasculature
.
[**2160-10-24**] RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: Using the
linear probe, grayscale and color Doppler son[**Name (NI) 1417**] of the right
common femoral, superficial femoral, and popliteal vessels were
performed. There is no intraluminal thrombus. The vessels
demonstrate normal flow, compressibility, respiratory
variability, and augmentation.
IMPRESSION: No evidence of DVT.


Brief Hospital Course:
A/P: 64 y.o male w/ h/o HCV cirrhosis s/p liver transplant, and
several other comorbidities presents s/p complete heart block.
.
#Paroxysmal AV Block: pt presented to OSH w/ AV block, possibly
secondary to hyperkalemia, which is thought to be due to pt's
FK506/tacrolimus.  Pt had temp pacer wire placed at OSH.  By
time of transfer to [**Hospital1 18**], pt was out of AB blocke & in NSR.
His temp line was eventually removed here as there were no
further signs of AV block.  He was monitored on telemetry.
Placement of permanent pacer delayed due infectious issues.  Pt
spiked temps, had (+) bld and line cx's--bld cx grew
enterococcus and PICC line grew coag negative staph.  Given
these issues, plan made for pt to have permanent pacer placed
after completion of 4wk course of antibiotics, followed by 2wks
of monitoring for fever and blood cultures.  If pt is fever free
and has no further positive cultures during this period, he will
go for pacemaker placement with Dr. [**Last Name (STitle) **] of [**Hospital1 18**].
.
# Infections: h/o MRSA, VRE and recurrent PNA.  Pt had recurrent
fevers during early part of hospital stay.  Fevers thought to be
due to bacteremia--bld cx's grew enterococcus (last (+) blood cx
from [**10-14**]), which was sensitive to vanco.  Pt's right PICC line
(from [**10-15**]) grew coag negative staph resistant to oxacillin.
Subsequent surveillane cultures were negative.  Source of
enterococcus in blood not identified.  Pt had pustule on LLE,
but not felt to be source of infection.  Pt had no further
positive blood cultures after those listed above.  He last
spiked a tempurate on the night of [**10-17**].  Pt did have
pseudomonas in the sputum, which was treated for a period with
cefepime.  However, pt had little evidence of respiratory
infection and the pseudomonas was thought to be colonizers, thus
the cefepime was discontinued.  Pt underwent TEE which was
negative for endocarditis or paravalvular abscess.
Given no clear source for enterococcal baceremia & plan for
pacemaker in near future, ID recommended longer course of Abx--4
weeks total, starting from date of last positive blood culture
[**2160-10-15**].  It may be possible to change to ampicillin for
treatment of enterococcal infection (since amp sensitive);
however, this was not done as pt's right arm still emdematous &
slightly erythematous from thrombophlebitis (from initial PICC
line, which grew coag negative staph, resistant to oxacillin).
If pt's right arm improves in appearance, suggesting clearance
of thrombophlebitis, vanco could be changed to ampicillin.
.
# Hyperkalemia: worked up thoroughly.  Primary cause thought to
be pt's KF506/tacrolimus.  Unfortunately, pt required increased
dose of FK506 to keep FK level in target range, which led to
frequent elevations in potassium.
Pt was treated aggressively with kayexylate & K improved.  EKG's
did not show changes associated with elevated K.
.
# Liver transplant: LFTs bumped [**10-18**], then resolved after
discontinuation of fluconazole, which was thought to be the
cause.  No clear evidence of rejection.  U/S unremarkable.  FK
level monitored closely and adjusted for goal level of 4 to 6.
Pt continued on prednisone and prophylactic bactrim.
.
# Anemia: pt has baseline anemia of chronic disease.  Stools
guaiac negative.  Baseline Hct mid to low 20's.  23.4 on day of
discharge.  Pt treated with Epogen & iron.
.
# Baslic vein thrombophbletis: partial, non-occlusive thrombosis
of Right basilic vein on U/S.  Associated swelling & mild
erythema.  No abscess on U/S.  Treated symptomatically.
.
# DM2: Pt's glucose was managed with humalog sliding scale &
daily glargine.
.
# Tracheostomy: 02 via trach mask at 35%. Satting in mid to high
90's.  Albuterol & atrovent given PRN
.
# Chronic renal insufficiency: developed post-liver transplant.
Cause not completely clear.  Baseline Crt 1.5 - 2.2; pt
currently 1.9.
.
# Pain: due to basilic thrombophlebitis and rib pain from
coughing.  Treated pain control with morphine sulfate immediate
release PO.
.
# Anxiety/Bipolar Depression: Pt treated w/ Ativan PRN for
anxiety & zyprexa for bipolar.  Social work was asked to see
him; however, he refused intervention.
.
# H/o diastolic dysfunction: Pt stable throughout admission.
Repeat echo (EF>65%) & mild LVH, trivial MR & TR.
.
#Right leg pain: on morning of discharge, pt complained pain on
right posterior thigh.  Pt reports it feels "muscular" in
nature, and that he "slept on it wrong."  However, given his
risk for DVT, lower ext u/s was performed, which showed no
evidence of DVT.  Physical exam was unremarkable.  Pain resolved
w/ MSIR.
.
# FEN: pt requires pureed diet based on previous swallow study.

.
# Prophylaxis: SC Heparin, Protonix, bowel regimen PRN
.
# code status: FULL




Medications on Admission:
Prograf 1 mg [**Hospital1 **]
Bactrim DS one tablet per day
Keflex 500mg PO q6H
Diflucan 200mg PO daily
Prednisone 5mg PO daily
Norvasc 10 mg PO daily
Protonix 40mg PO daily
Olanzapine 2.5mg PO daily
zinc sulfate 220 mg po daily
sliding scale insulin PRN
Heparin 5000 units subcutaneously TID
Ativan 1mg PO q6H PRN
Motrin 600mg PO PRN
Hydromorphone 0.5-2mg IV q2H PRN
Artificial tears
Miconazole powder PRN


Discharge Medications:
1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic  PRN
(as needed).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  PRN
(as needed).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID, PRN ().
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheeze.
14. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
15. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
16. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety/insomnia.
18. Insulin Lispro (Human) 100 unit/mL Solution Sig: per Insulin
Flowsheet/sliding scale  Subcutaneous qACHS.
19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous  Q8H (every 8 hours) as needed for nausea.
20. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  Q 24H (Every 24 Hours) for 20 days.
21. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QAM (once
a day (in the morning)) as needed for s/p liver transplant.
22. Tacrolimus 0.5 mg Capsule Sig: Two (2) Capsule PO QPM (once
a day (in the evening)).
23. Sodium Polystyrene Sulfonate 15 g/60mL Suspension Sig: Two
(2)  PO q2HR PRN hyperkalemia  for 1 doses.
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
25. Insulin Glargine 100 unit/mL Solution Sig: 10units
Subcutaneous once a day.
26. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Primary:
Paroxysmal AV Block
Hyperkalemia due to FK506 (tacrolimus)
Enterococcal Bacteremia
Coagulase negative staphyloccocal PICC infection
Right Basilic vein thrombophlebitis
.
Secondary:
Orthotopic Liver Transplant
Diabetes (type II)
tracheostomy
Bipolar d/o
Chronic Kidney Disease
H/o VRE & MRSA


Discharge Condition:
Good, afebrile x 7 days, cultures no growth since [**2160-10-15**],
minimal activity, potassium 4.1 BUN 34 Crt 1.9


Discharge Instructions:
You were admitted to the hospital with an irregular heart
rhythm.  This resolved on its own, and did not recurr.  However,
you will need to get a pacemaker in the future, once your blood
infection is fully treated.
.
If you have chest pain, shortness of breath, faint, fever, rash,
nausea, vomiting, diarrhea, bloody stools, abdominal pain,
please contact a doctor or go to the emergency room.
.
MR. [**Known lastname 1182**] will require a number of blood tests be drawn
regularly, see below.
.
1. Potassium should be checked on [**2160-10-26**] and treated PRN.
.
2. Weekly, on Wednesdays, CBC with differential, BUN, & Crt,
LFTs and vancomycin trough need to be checked. These results
should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].
.
3. Weekly, on Wednesdays, FK506 (aka tacrolimus) levels,
potassium, liver function tests need to be checked in the AM, 12
hours after the PM dose of FK506/tacrolimus was given.  These
results need to be faxed to [**Doctor Last Name 1022**], attention "Transplant
Coordinator" in the [**Hospital1 **] Transplant Department.
 Fax # [**Telephone/Fax (1) 697**].
.
4. Blood cultures need to be drawn at the rehab facility on
[**2160-11-14**] and [**2160-11-21**].  Please fax the results of these to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] at [**Telephone/Fax (1) 1419**].

Followup Instructions:
The patient has the following appointments scheduled:
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **], MD (PCP)  [**Telephone/Fax (1) 45347**]  Appointment
should be in [**6-16**] days
.
DR. [**First Name (STitle) **] [**Doctor Last Name 9406**] (of infectious disease at [**Hospital3 **]
[**Hospital 1225**] Medical Center in [**Location (un) 86**]) Date/Time:[**2160-11-18**] 11:00
Phone:[**Telephone/Fax (1) 457**]--call if you have questions or need
directions.
.
DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (of electrophysiology) Date/Time:[**2160-11-20**]
1:00  Phone:[**Telephone/Fax (1) 2934**]
.
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2160-12-18**] 10:00


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
{'Streptococcal septicemia,Sepsis,Atrioventricular block, complete,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute respiratory failure,Diastolic heart failure, unspecified,Liver replaced by transplant,Chronic kidney disease, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hyperpotassemia,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Tracheostomy status,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified local infection of skin and subcutaneous tissue'}


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: Complete Heart Block & Ventricular Tachycardia

PRESENT ILLNESS: 64yo man w/ h/o multiple medical problems including [**Name (NI) 2320**], CAD,
HepC/ETOH cirrhosis & HCC s/p orthotopic liver tx ('[**57**]) on
prograf w/ post-transplant course complicated by renal
insufficiency, tracheostomy, chronic colonization/infections w/
mult resistant organisms who was transferred from [**Location (un) 745**]
[**Hospital 3714**] Hospital to [**Hospital1 18**] CCU for pacemaker/ICD placement.  Pt
initially presented to NWH on [**2159-10-13**] w/ & AV block in setting
of hyperkalemia.  Pt tx'd w/ RIJ temporary pacing wire at NWH,
during which he developed Ventricular Tachycardia.  Pt out of AV
block, and in sinus rhythm upon arrival at [**Hospital1 18**].

MEDICAL HISTORY: 1. Liver transfusion for Hepatitis C/EtOH cirrhosis &
hepatocellular carcinoma, on tacrolimus followed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 497**].
2. Tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

MEDICATION ON ADMISSION: Prograf 1 mg [**Hospital1 **]
Bactrim DS one tablet per day
Keflex 500mg PO q6H
Diflucan 200mg PO daily
Prednisone 5mg PO daily
Norvasc 10 mg PO daily
Protonix 40mg PO daily
Olanzapine 2.5mg PO daily
zinc sulfate 220 mg po daily
sliding scale insulin PRN
Heparin 5000 units subcutaneously TID
Ativan 1mg PO q6H PRN
Motrin 600mg PO PRN
Hydromorphone 0.5-2mg IV q2H PRN
Artificial tears
Miconazole powder PRN

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: VS: T: 99.2 HR: 70 RR: 19 bp: 131/91 SpO2: 97% on ventilatory
mask 0.35 FIO2
Gen: A&O*4, appears mildly distressed
HEENT: PERRLA, EOMI, 2mm pupils
Neck: trach, pacemaker insertion site C/D/I
Heart: temp pacemaker set at HR 50/ 10mV, RRR
Lung: coarse rhonchi louder on LLL than RLL
Abd: soft, NT, ND
Ext: 0.5cm pustule on distal lateral LLE surrounded by 1 cm
erythematous border

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs. 

### Response:
{'Streptococcal septicemia,Sepsis,Atrioventricular block, complete,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute respiratory failure,Diastolic heart failure, unspecified,Liver replaced by transplant,Chronic kidney disease, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hyperpotassemia,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Tracheostomy status,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Unspecified local infection of skin and subcutaneous tissue'}
