CHIEF COMPLAINT: Dyspnea on exertion

PRESENT ILLNESS: 66 y/o man with H/O CAD, s/p CABG in [**2169**], s/p prior
catheterization showing the LIMA-LAD is the only remaining
patent graft, s/p ICD in [**2177**] for primary prevention against
sudden cardiac death, and s/p right upper lobectomy for lung
cancer in [**2172**] with adjunctive chemotherapy and radiation. He
has done well over the past few years until about 2-3 weeks ago
when his cardiologist, Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**], interrorgted his
device and found he was having numerous episodes of VT (100 or
so episodes without ICD firing). His verapamil was discontinued,
and he was started on Quinaglute (did not start amiodarone due
to lung issues). He returned and was found to have no VT.
However, on [**2181-10-15**] he presented to [**Hospital6 20592**] with shortness of breath and orthopnea; he also stated
that he has been increasingly dyspneic with exertion over the
past few weeks. His blood pressure was down in the 80-90
systolic range and his BNP was in the 700's. He had lower
extremity edema. He was admitted, had no biomarker evidence of
MI, was diuresed, and underwent an echocardiogram yesterday
showing an EF of 30% which was essentially unchanged, but he was
found to have new 3+ mitral regurgitation and hypokinesis of the
inferior wall.

MEDICAL HISTORY: 1. Hypertension
2. Hyperlipidemia
3. CAD, s/p CABG in [**2169**] (LIMA-LAD, SVG-Ramus, SVG-RCA), s/p
cath on [**2177-9-10**] found to have totally occluded SVG-Ramus and
SVG-RCA. The native RCA was totally occluded; he had a 30% left
main lesion and a 80% ramus lesion. It was at this time he was
found to have a lesion in his left subclavian and had a stent
placed there.
4. Cardiomyopathy/chronic LV systolic heart failure with EF of
30% s/p ICD in [**2177**].
5. Lung cancer, s/p right upper lobectomy, chemo, & XRT
6. Asthma
7. Gout
8. Diabetes mellitus

MEDICATION ON ADMISSION: Albuterol inhaler
Flunisolide 250 mcg, two puffs [**Hospital1 **]
Quinaglute 324 mg tid
Flovent inhaler
Foradil 12 mcg 1 inhaled [**Hospital1 **]
Captopril 25 mg [**Hospital1 **]
Crestor 40 mg daily
Aspirin 325 mg daily
Lasix 60 mg [**Hospital1 **]
Spironolactone 25 mg daily
Indomethacin 25 mg qid prn
Metoprolol 25 mg [**Hospital1 **]
Nasonex 50 mc 1 puff each nostril [**Hospital1 **]
Nitro sublingual prn
Verapamil 120 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: WDWN middle aged Caucasian man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98.4  BP 107/69  HR 94  RR 18  O2sat 100% on 2 L/min NC
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs, rubs or gallops. No thrills,
lifts.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation. No abdominal bruits.
Ext: No clubbing, cyanosis or edema. No carotid bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left:  Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: There is a family history of CAD: his father had an MI, mother
had a CVA.

SOCIAL HISTORY: Significant for 60 py smoking history, and the patient quit
smoking in [**2172**]. There is no history of alcohol abuse.
Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Personal history of malignant neoplasm of bronchus and lung,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Asthma, unspecified type, unspecified,Other primary cardiomyopathies,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ,Hypovolemia
Crnry athrscl natve vssl,Acute kidney failure NOS,Parox ventric tachycard,Chr syst/diastl hrt fail,Mitral valve disorder,Hx-bronchogenic malignan,DMII wo cmp nt st uncntr,Gout NOS,Asthma NOS,Prim cardiomyopathy NEC,Hypertension NOS,Status autm crd dfbrltr,Hypovolemia
Admission Date:  [**2181-10-16**]              Discharge Date:   [**2181-10-23**]

Date of Birth:  [**2115-2-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor Last Name 1857**]
Chief Complaint:
Dyspnea on exertion

Major Surgical or Invasive Procedure:
Cardiac catheterization [**2181-10-17**]
Stenting of the left main coronary artery [**2181-10-18**]

History of Present Illness:
66 y/o man with H/O CAD, s/p CABG in [**2169**], s/p prior
catheterization showing the LIMA-LAD is the only remaining
patent graft, s/p ICD in [**2177**] for primary prevention against
sudden cardiac death, and s/p right upper lobectomy for lung
cancer in [**2172**] with adjunctive chemotherapy and radiation. He
has done well over the past few years until about 2-3 weeks ago
when his cardiologist, Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**], interrorgted his
device and found he was having numerous episodes of VT (100 or
so episodes without ICD firing). His verapamil was discontinued,
and he was started on Quinaglute (did not start amiodarone due
to lung issues). He returned and was found to have no VT.
However, on [**2181-10-15**] he presented to [**Hospital6 20592**] with shortness of breath and orthopnea; he also stated
that he has been increasingly dyspneic with exertion over the
past few weeks. His blood pressure was down in the 80-90
systolic range and his BNP was in the 700's. He had lower
extremity edema. He was admitted, had no biomarker evidence of
MI, was diuresed, and underwent an echocardiogram yesterday
showing an EF of 30% which was essentially unchanged, but he was
found to have new 3+ mitral regurgitation and hypokinesis of the
inferior wall.

Dr. [**Last Name (STitle) 1911**] had the patient transferred here for right and
left heart catheterization.

ROS: He denies any prior history of stroke, TIA, DVT, PE,
bleeding at the time of surgery, myalgias, joint pains, cough,
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. Cardiac review of
systems is notable for absence of chest pain, paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.

Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. CAD, s/p CABG in [**2169**] (LIMA-LAD, SVG-Ramus, SVG-RCA), s/p
cath on [**2177-9-10**] found to have totally occluded SVG-Ramus and
SVG-RCA. The native RCA was totally occluded; he had a 30% left
main lesion and a 80% ramus lesion. It was at this time he was
found to have a lesion in his left subclavian and had a stent
placed there.
4. Cardiomyopathy/chronic LV systolic heart failure with EF of
30% s/p ICD in [**2177**].
5. Lung cancer, s/p right upper lobectomy, chemo, & XRT
6. Asthma
7. Gout
8. Diabetes mellitus

Social History:
Significant for 60 py smoking history, and the patient quit
smoking in [**2172**]. There is no history of alcohol abuse.

Family History:
There is a family history of CAD: his father had an MI, mother
had a CVA.

Physical Exam:
Gen: WDWN middle aged Caucasian man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98.4  BP 107/69  HR 94  RR 18  O2sat 100% on 2 L/min NC
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs, rubs or gallops. No thrills,
lifts.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation. No abdominal bruits.
Ext: No clubbing, cyanosis or edema. No carotid bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left:  Carotid 2+ DP 2+ PT 2+

Pertinent Results:
Admission Labs:
WBC-13.8* RBC-4.20* Hgb-12.9* Hct-38.9* MCV-93# MCH-30.7#
MCHC-33.2 RDW-14.1 Plt Ct-203
Neuts-87.1* Lymphs-9.9* Monos-2.9 Eos-0.1 Baso-0.1
Glucose-136* UreaN-32* Creat-1.4* Na-137 K-4.2 Cl-98 HCO3-30
ALT-24 AST-18 AlkPhos-74 TotBili-0.3 DirBili-0.1 IndBili-0.2
Calcium-9.3 Phos-3.7 Mg-2.3

Discharge Labs:
WBC-7.1 RBC-3.82* Hgb-11.7* Hct-35.3* MCV-92 MCH-30.5 MCHC-33.0
RDW-14.1 Plt Ct-217
PT-12.9 PTT-27.3 INR(PT)-1.1
Glucose-97 UreaN-21* Creat-1.2 Na-138 K-4.1 Cl-97 HCO3-33*
Calcium-8.4 Phos-3.3 Mg-2.2

CXR [**2181-10-16**]
No appreciable interval change. Patient has had right upper lung
and chest wall resection. There is mild scarring in the left mid
lung unchanged over four years, no pleural effusion or pulmonary
consolidation noted. Heart size normal. Transvenous right atrial
pacer and right ventricular pacer defibrillator leads follow
their expected courses unchanged and continuous from the left
pectoral pacemaker.

ECG [**2181-10-17**] 1:46:26 AM
Sinus rhythm and paroxysmal atrial fibrillation with ventricular
rate 143 bpm. The limb leads are misattached. There is evidence
for prior inferoposterior and lateral myocardial infarction.
Right bundle-branch block. Compared to the previous tracing of
[**2177-10-30**] paroxysmal atrial fibrillation has appeared. Otherwise,
no apparent diagnostic interim change.

Cardiac catheterization [**2181-10-17**]
  1. Selective coronary angiography in this right dominant
system revealed three vessel native coronary artery disease. The
LMCA was heavily calicified with ostial 70% stenosis and distal
40% stenosis; there was some pressure dampening when the LMCA
was engaged with the JL4 diagnostic catheter. The LAD had
proximal diffuse disease, was heavily calcified, and had
competitive flow in the mid-LAD; there were apical collaterals
to the RCA. The LCX was moderately calcified with a hazy origin
stenosis of at least mild-moderate severity. A high OM1 had
diffuse severe disease after a proximal taper. There was a major
patent OM2. The OM3/LPL was of modest caliber. The distal AV
groove CX supplied an atrial branch and faint collaterals to the
RCA. The RCA had a proximal total occlusion with faint filling
of AMs.
  2. Selective venous conduit angiography was not performed as
the SVG's were known to be occluded. Selective conduit
arteriography revealed a patent LIMA arising adjacent to the
thyrocervical trunk. The proximal left subclavian artery stent
was patent, with a 20 mnHg gradient in the subclavian distal to
the LIMA origin. The LIMA had a mild kinking mid graft and a
mild anastomotic lesion; there was retrograde filling of a large
diagonal and aterograde filling of the apical LAD with
collaterals to the RCA. There was a 50% lesion at the origin of
the vertebral artery.
  3. Abdominal aortography using an angled pigtail catheter just
below the level of the renal arteries revealed no apparent renal
artery stenosis. There was extensive distal abdominal aortic
disease with plaque at the origin of the right iliac artery and
a 60-70% stenosis at the origin of the left iliac artery. There
was calcific atherosclerosis in both femoral arteries. The right
femoral artery had been noted to be heavily calcified during
arterial access.
  4. Resting hemodynamics revealed normal systemic blood
pressure with SBP of 101 mmHg, elevated right and left sided
filling pressures with RVEDP of 13 mmHg and mean PCWP of 22
mmHg. There was pulmonary arterial hypertension with PASP of 45
mmHg. The cardiac index was preserved at 2.7 l/min/m2 (using an
assumed oxygen consumption).

Echocardiogram [**2181-10-17**]
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is
severely depressed (LVEF= 25 %) with akinesis to dyskinesis of
thinned inferior and infero-lateral walls. The basal septum
moves best and the remaining segments are hypokinetic. There is
no ventricular septal defect. with normal free wall
contractility. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.

PCI [**2181-10-18**]
1.  Selective coronary angiography of this right dominant system
demonstrated a severly diseased left main coronary artery
extending into the proximal left circumflex and left main
coronary artery.  The mid to distal portion of the left anterior
descending artery filled by a patent LIMA.  The right coronary
artery was not engaged.
2.  Successful prophylactic placement of an IABP via the left
femoral artery for cardiogenic support during PCI.
3.  Successful stenting of the left main coronary artery
extending into the proximal left circumflex artery with a Xience
(3x23mm) drug eluting stent postdilated with a 3.5mm balloon.
Final angiography demonstrated no angiographically apparent
dissection, no residual stenosis and TIMI III flow throughout
the vessel.
4.  Successful closure of the right femoral arteritomy site with
a 6F Mynx closure device.

Right Knee X-rays [**2181-10-20**]
Right medial post-surgical clips projecting over the soft
tissues. Extensive vascular calcifications. Subtle dot-like
radiopaque particles projecting 6 cm caudal of the tibial head
on the AP projection. Minimal linear calcifications projecting
into the joint space. There is no evidence of traumatic bone
injury.

Brief Hospital Course:
66 y/o man with H/O CAD, congestive systolic heart failure, and
lung cancer with worsening dyspnea on exertion. History of
numerous VT episodes on recent ICD interrogation.

# CAD - Known severe coronary artery disease. Cardiac
catheretizations this admission showed PCW 22 and LVEDP 26 mm Hg
with preserved cardiac index. He had severe LMCA and three
vessel disease with patent proximal left subclavian artery stent
and patent LIMA-LAD. Abdominal aortography showed extensive
aortic and iliac disease, precluding using of the Impella Assist
Device. In consultation with Dr. [**Last Name (STitle) 1911**], the decision was
made to proceed with high risk PCI of the protected LMCA with
IABP support. This procedure was delayed for several hours due
to arrhythmias (see below), but on [**10-18**], a Xience DES was placed
in the LMCA into the circumflex artery with right femoral
arteriotomy closure using the Mynx device and IABP secured in
place in the left femoral artery. The patient was stable after
the balloon pump was removed. He was continued on maximal
medical management with aspirin, Plavix, metoprolol, and
rosuvastatin.

# Pump - Has severe chronic systolic and diastolic left
ventricular heart failure with recent acute exacerabtion with
recent EF of 25% and akinesis to dyskinesis of thinned inferior
and infero-lateral walls with slightly dilated LV wall. Repeat
echocardiogram here showed moderate eccentric mitral
regurgitation, prompting the decision to revascularize the
native circumflex in hopes of reducing papillary muscle ischemic
dysfunction. His filling pressures were elevated at
catheterization. Lasix and spironolactone were continued, and
captopril was decreased then changed to low dose lisinopril due
to hypotension.

# Rhythm - Has a pacer and ICD. Patient did have VT upon
interrogation of ICD prior to admission; unclear etiology for
this, but likely secondary to ischemia. He had recurrent SVT
during this admission with HRs into 160s, mostly asymptomatic
with relatively low BPs which are now close to baseline. He was
on an amiodarone drip for three days, but then switched back to
quinidine, increased to QID instead of his prior dosing at TID.
He triggered for atrial fibrillation with VR to 160 the night
prior to discharge, however, he had not received his quinidine
or metoprolol that evening. He was asymptomatic and his
arrhythmia resolved after receiving these medications. He was
evaluated by EP who felt that no further changes to his
pacer/ICD settings were needed at this time. They may consider
ablation in the future if recurrent VT is originating from a
scar. He is not anticoagulated at this time. This can be
considered in the future if atrial fibrillation returns. His
dose of metoprolol was increased on this admission.

# Dyspnea - The patient's dyspnea was likely multifactorial
including past lobectomy, worsening heart failure, and asthma.
He received ipratropium, fluticasone, salmeterol prn. The
patient's dyspnea at rest resolved, however, he desaturated to
84% on room air with amublation the day prior to discharge and
again on the of discharge, despite receiving extra Lasix. He was
discharged to home with oxygen and pulmonary rehab. He has not
previously had home oxygen.

# Diabetes mellitus - The patient was placed on an insulin
sliding scale with good blood sugar control.

# Knee pain - A few days prior to discharge, the patient
developed a painful right knee. The patient was afebrile and the
knee was not warm. It was felt that his knee pain was most
consistent with a gout flare. He was given indomethacin for 24
hours with resolution of his knee pain. This medication was
discontinued due to its potential to interfere with the
antiplatelet effects of aspirin. He was discharged with a
prescription for a prednisone burst-taper in the event that his
symptoms recur.

# Mild Acute Renal Function - The patient had a creatinine
elevated to 1.4 on admission, likely due to hypovolemia and poor
foward flow from CHF. With pre-hydration prior to
catheterization and judicious diuresis, his creatinine had
returned to a baseline of 1.2 on the day of discharge.

Medications on Admission:
Albuterol inhaler
Flunisolide 250 mcg, two puffs [**Hospital1 **]
Quinaglute 324 mg tid
Flovent inhaler
Foradil 12 mcg 1 inhaled [**Hospital1 **]
Captopril 25 mg [**Hospital1 **]
Crestor 40 mg daily
Aspirin 325 mg daily
Lasix 60 mg [**Hospital1 **]
Spironolactone 25 mg daily
Indomethacin 25 mg qid prn
Metoprolol 25 mg [**Hospital1 **]
Nasonex 50 mc 1 puff each nostril [**Hospital1 **]
Nitro sublingual prn
Verapamil 120 mg daily

Discharge Medications:
1. Prednisone 10 mg Tablet Sig: taper as outlined below Tablet
PO once a day for 5 days: Take 50 mg on day 1, then 40 mg on day
2, then 30 mg on day 3, then 20 mg on day 4, then 10 mg on day
5, then stop. Disp:*15 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Quinidine Gluconate 324 mg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO Q6H (every 6 hours). Disp:*120
Tablet Sustained Release(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day). Disp:*90 Tablet(s)* Refills:*2*
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*2*
11. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-24**]  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
12. Flunisolide 250 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
13. Foradil Aerolizer 12 mcg Capsule, w/Inhalation Device Sig:
One (1)  Inhalation twice a day.
14. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
Nasal twice a day.
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Oxygen 2L continuous
17. please provide tubing for oxygen

Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Primary Diagnoses:
Coronary artery disease, treated with
Drug-eluting stent deployment in the left main and circumflex
coronary arteries
Acute on chronic left ventricular systolic and diastolic
congestive heart failure

Secondary Diagnoses:
Gout
Atrial fibrillation
Supraventricular tachycardia
Ventricular tachycardia
Diabetes mellitus
Prior lung cancer
Asthma
Hypoxemia
Acute renal failure
Mitral regurgitation

Discharge Condition:
stable, afebrile, SBPs in 80s-100s, breathing comfortably on 2L
O2.  Desats to 84% on room air with ambulation.

Discharge Instructions:
You were admitted to the hospital for worsening shortness of
breath.  It was thought to be due to your heart.  You had a
catheterization that showed an artery that needed a stent.  You
had another catheterization in which the stent was placed, and
then you were monitored in the intensive care unit while you had
a balloon pump helping your blood pressure stay high.  You
continued to have low oxygen saturations while walking, dropping
to 84% and will need to go home with oxygen.

You did well post cath.  You had a few arrhythmias, so the
electrophysiologists saw you and helped us adjust your
medicines.

The following changes were made in your medications: your
captopril was stopped and changed to a lower dose of a similar
medication called lisinopril. Your metoprolol dose was increased
to 100 mg daily. Your diuretic was doubled to 60 mg twice daily.
Your quinidine was increased from three to four times daily (~
every 6 hours). You were also started on two new medications:
clopidogrel 75 mg daily and digoxin 0.125 mg daily. You have
been given prescriptions for these changes.

You also developed knee pain which improved after a few doses of
indomethacin.  This may have been a gout attack, however, the
indomethacin was stopped because it may interfere with aspirin.
If your knee pain or other gout symptoms return, you should take
a short course of a steroid medication called prednisone instead
of indomethacin.  You have been given a prescription for this
should you need it.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.

Please call your physician or return to the hospital if you
develop worsening shortness of breath, chest pain, fevers,
swelling in your feet, or other concerning symptoms.

Followup Instructions:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2181-11-22**] 1:00

                             [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **] MD, MSC 12-339
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Personal history of malignant neoplasm of bronchus and lung,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Asthma, unspecified type, unspecified,Other primary cardiomyopathies,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ,Hypovolemia'}


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: Dyspnea on exertion

PRESENT ILLNESS: 66 y/o man with H/O CAD, s/p CABG in [**2169**], s/p prior
catheterization showing the LIMA-LAD is the only remaining
patent graft, s/p ICD in [**2177**] for primary prevention against
sudden cardiac death, and s/p right upper lobectomy for lung
cancer in [**2172**] with adjunctive chemotherapy and radiation. He
has done well over the past few years until about 2-3 weeks ago
when his cardiologist, Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**], interrorgted his
device and found he was having numerous episodes of VT (100 or
so episodes without ICD firing). His verapamil was discontinued,
and he was started on Quinaglute (did not start amiodarone due
to lung issues). He returned and was found to have no VT.
However, on [**2181-10-15**] he presented to [**Hospital6 20592**] with shortness of breath and orthopnea; he also stated
that he has been increasingly dyspneic with exertion over the
past few weeks. His blood pressure was down in the 80-90
systolic range and his BNP was in the 700's. He had lower
extremity edema. He was admitted, had no biomarker evidence of
MI, was diuresed, and underwent an echocardiogram yesterday
showing an EF of 30% which was essentially unchanged, but he was
found to have new 3+ mitral regurgitation and hypokinesis of the
inferior wall.

MEDICAL HISTORY: 1. Hypertension
2. Hyperlipidemia
3. CAD, s/p CABG in [**2169**] (LIMA-LAD, SVG-Ramus, SVG-RCA), s/p
cath on [**2177-9-10**] found to have totally occluded SVG-Ramus and
SVG-RCA. The native RCA was totally occluded; he had a 30% left
main lesion and a 80% ramus lesion. It was at this time he was
found to have a lesion in his left subclavian and had a stent
placed there.
4. Cardiomyopathy/chronic LV systolic heart failure with EF of
30% s/p ICD in [**2177**].
5. Lung cancer, s/p right upper lobectomy, chemo, & XRT
6. Asthma
7. Gout
8. Diabetes mellitus

MEDICATION ON ADMISSION: Albuterol inhaler
Flunisolide 250 mcg, two puffs [**Hospital1 **]
Quinaglute 324 mg tid
Flovent inhaler
Foradil 12 mcg 1 inhaled [**Hospital1 **]
Captopril 25 mg [**Hospital1 **]
Crestor 40 mg daily
Aspirin 325 mg daily
Lasix 60 mg [**Hospital1 **]
Spironolactone 25 mg daily
Indomethacin 25 mg qid prn
Metoprolol 25 mg [**Hospital1 **]
Nasonex 50 mc 1 puff each nostril [**Hospital1 **]
Nitro sublingual prn
Verapamil 120 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: WDWN middle aged Caucasian man in NAD. Oriented x3. Mood,
affect appropriate.
VS: T 98.4  BP 107/69  HR 94  RR 18  O2sat 100% on 2 L/min NC
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs, rubs or gallops. No thrills,
lifts.
Chest: No chest wall deformities, scoliosis or kyphosis.
Respirations were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abdominal aorta not
enlarged by palpation. No abdominal bruits.
Ext: No clubbing, cyanosis or edema. No carotid bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left:  Carotid 2+ DP 2+ PT 2+

FAMILY HISTORY: There is a family history of CAD: his father had an MI, mother
had a CVA.

SOCIAL HISTORY: Significant for 60 py smoking history, and the patient quit
smoking in [**2172**]. There is no history of alcohol abuse. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Paroxysmal ventricular tachycardia,Chronic combined systolic and diastolic heart failure,Mitral valve disorders,Personal history of malignant neoplasm of bronchus and lung,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Asthma, unspecified type, unspecified,Other primary cardiomyopathies,Unspecified essential hypertension,Automatic implantable cardiac defibrillator in situ,Hypovolemia'}
