CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: This is a 49 year-old male with a history of HBV hepatitis on
entecavir , hypercholesterolemia, family history of premature
CAD who presents with leg swelling and progressive SOB.
.
Worked up in late [**2125-12-10**] for week or so of cough, told he
had pneumonia by CXR, received 5 days of azyhtromycin w/o any
improvement in his cough. Got second CXR around [**12-24**]
findings had not cleared got another course of 5 days
Azithromycin which he finished 7 days prior to presentation
again w/o improvement in cough. During this period except for
cough complained of exertional dyspnea which has progressed
rapidly over the past week from 20 stairs to dyspnea at rest.
Admits to orthopnea two or more pillows, describes paroxysmal
cough at night but not PND. Noticed 11 lb weight gain over past
two months.  No nocturia. Denies chest pain. Two days prior to
admission had CT chest which showed diffuse bilateral
ground-glass infiltrates consistent with infectious process,
most likely atypical or viral pneumonia as well as bilateral
pleural effusions.  On day prior to admission noticed swelling
on right foot followed later by left foot swelling. Saw his PCP
who sent him to the ER.
.
  Does not recall recent febrile illness. Believes all his
symptoms started after  "overworked" himself in the gym around
Thanks Giving and had to spend a day in bed because of general
muscle soarness and chest pain. Patient has no history of HF or
coronary disease. Denies any recent travels. No contacts with
animals. No bites or stings. No contact with [**Name2 (NI) **] people. Was
vaccinated for Flu in early novemebr.
.
In the ED, admission vitals were: 99.9 121 134/91 20 100% on 4L
O2. He triggered for tachypnea 30-40 and dested to high 80's in
RA. Found to have right leg swelling, LENI was negative for DVT
as was CTA for PE. CTA did show multifocal ground glass
opacities and bil mod pleural effusions R>L essentially
unchanged from CT of 2 days prior. Labs showed unremarkable CBC,
chemistry remarkable for HCO3 = 21 with normal anion gap.
d-dimer was 3019. trop X 1 was negative. Patient was given 1
dose of ceftriaxone + levoflox in the ED (1900). His transfer
vitals were HR 112 BP 123/88 RR 34 Sat 95%4l
.
ROS:
+ nausea over past few days
- denies any fevers, nausea, vomiting, abdominal pain, diarrhea,
constipation, melena, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash.
.

MEDICAL HISTORY: - HBV hepatitis: biopsy [**7-/2125**] grade 2 inflammation and stage I
fibrosis on Entecavir with good response and normalized LFT's.
- Hypercholesterolemia
- bil varicocele surgery [**2108**]

MEDICATION ON ADMISSION: multivitamin QD
Pravastatin 10mg QD
entecavir 0.5 mg tablet daily.
Aspirin daily was recommended but is not taking it

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical:
.
Vitals: T: 97.5 BP: 136/95 HR: 107 RR: 37 O2Sat: 95% or 5L
GEN: tachypnic but not dyspnic, not in distress, completes full
sentenses, A+O x3, cooperative
HEENT: EOMI, PERRLA, sclera anicteric, MMM, OP Clear
NECK: No JVD but HJR is positive, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: limited by breath sounds but essentiall rapid RRR, no
M/G/R, normal S1 S2. Radial pulses +1
PULM: Lungs bil wet crackles to [**2-11**] hight of chest, no Wheezing,
reduced breath sounds and fremitus on bilateral bases,
precussion is symetrical and hypotympanic at bases
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No clubbing or cyanosis. Right calf > Left calf, no calf
tenderness, neg [**Last Name (un) **] sign, bil trace pre-tibial edema.
NEURO: grossly intact
SKIN: no stigmata of chronic liver disease
.
Discharge physical:
.
VS: Tm 98.4, 104/73-107/75, HR 89, RR 18, 96% RA
GENERAL: well-appearing man. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with elevated JVP, at angle of jaw
CARDIAC: RR, normal S1, S2. No m/r/g. S3 audible at RUSB. ICD
pocket in upper L chest, no tenderness or hematoma
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds at bases, faint rales bibasilarly,
improved from yesterday
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no pedal edema, no femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
1cm raised erythematous lesion above sternum, appears like hive
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Family Medical History:
Mother - CAD after age 55, CABG, DM type 2, HTN
Father - died at age 72, ESRD
3 brothers, 1 sister: sister with type 2 DM. Brother underwent
CABG at 50y.

SOCIAL HISTORY: Allergies:  NKDA
.
Social History:  Born in [**Location (un) 6847**], emmigrated to US at age 1y.
Accountant. Married + 1 daughter aged 15. ADL independent. No
etoh. No tobacco, no illicit. Monogamous sexuall relations with
wife.
Congestive heart failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Alkalosis,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Family history of ischemic heart disease
CHF NOS,Hpt B acte wo cm wo dlta,Alkalosis,Crnry athrscl natve vssl,Ill-defined hrt dis NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Fam hx-ischem heart dis
Admission Date:  [**2126-3-11**]              Discharge Date:   [**2126-3-18**]

Date of Birth:  [**2077-3-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization
Internal cardiac defibrillator placement


History of Present Illness:
This is a 49 year-old male with a history of HBV hepatitis on
entecavir , hypercholesterolemia, family history of premature
CAD who presents with leg swelling and progressive SOB.
.
Worked up in late [**2125-12-10**] for week or so of cough, told he
had pneumonia by CXR, received 5 days of azyhtromycin w/o any
improvement in his cough. Got second CXR around [**12-24**]
findings had not cleared got another course of 5 days
Azithromycin which he finished 7 days prior to presentation
again w/o improvement in cough. During this period except for
cough complained of exertional dyspnea which has progressed
rapidly over the past week from 20 stairs to dyspnea at rest.
Admits to orthopnea two or more pillows, describes paroxysmal
cough at night but not PND. Noticed 11 lb weight gain over past
two months.  No nocturia. Denies chest pain. Two days prior to
admission had CT chest which showed diffuse bilateral
ground-glass infiltrates consistent with infectious process,
most likely atypical or viral pneumonia as well as bilateral
pleural effusions.  On day prior to admission noticed swelling
on right foot followed later by left foot swelling. Saw his PCP
who sent him to the ER.
.
  Does not recall recent febrile illness. Believes all his
symptoms started after  "overworked" himself in the gym around
Thanks Giving and had to spend a day in bed because of general
muscle soarness and chest pain. Patient has no history of HF or
coronary disease. Denies any recent travels. No contacts with
animals. No bites or stings. No contact with [**Name2 (NI) **] people. Was
vaccinated for Flu in early novemebr.
.
In the ED, admission vitals were: 99.9 121 134/91 20 100% on 4L
O2. He triggered for tachypnea 30-40 and dested to high 80's in
RA. Found to have right leg swelling, LENI was negative for DVT
as was CTA for PE. CTA did show multifocal ground glass
opacities and bil mod pleural effusions R>L essentially
unchanged from CT of 2 days prior. Labs showed unremarkable CBC,
chemistry remarkable for HCO3 = 21 with normal anion gap.
d-dimer was 3019. trop X 1 was negative. Patient was given 1
dose of ceftriaxone + levoflox in the ED (1900). His transfer
vitals were HR 112 BP 123/88 RR 34 Sat 95%4l
.
ROS:
+ nausea over past few days
- denies any fevers, nausea, vomiting, abdominal pain, diarrhea,
constipation, melena, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash.
.

Past Medical History:
- HBV hepatitis: biopsy [**7-/2125**] grade 2 inflammation and stage I
fibrosis on Entecavir with good response and normalized LFT's.
- Hypercholesterolemia
- bil varicocele surgery [**2108**]


Social History:
Allergies:  NKDA
.
Social History:  Born in [**Location (un) 6847**], emmigrated to US at age 1y.
Accountant. Married + 1 daughter aged 15. ADL independent. No
etoh. No tobacco, no illicit. Monogamous sexuall relations with
wife.


Family History:
Family Medical History:
Mother - CAD after age 55, CABG, DM type 2, HTN
Father - died at age 72, ESRD
3 brothers, 1 sister: sister with type 2 DM. Brother underwent
CABG at 50y.


Physical Exam:
Admission physical:
.
Vitals: T: 97.5 BP: 136/95 HR: 107 RR: 37 O2Sat: 95% or 5L
GEN: tachypnic but not dyspnic, not in distress, completes full
sentenses, A+O x3, cooperative
HEENT: EOMI, PERRLA, sclera anicteric, MMM, OP Clear
NECK: No JVD but HJR is positive, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: limited by breath sounds but essentiall rapid RRR, no
M/G/R, normal S1 S2. Radial pulses +1
PULM: Lungs bil wet crackles to [**2-11**] hight of chest, no Wheezing,
reduced breath sounds and fremitus on bilateral bases,
precussion is symetrical and hypotympanic at bases
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No clubbing or cyanosis. Right calf > Left calf, no calf
tenderness, neg [**Last Name (un) **] sign, bil trace pre-tibial edema.
NEURO: grossly intact
SKIN: no stigmata of chronic liver disease
.
Discharge physical:
.
VS: Tm 98.4, 104/73-107/75, HR 89, RR 18, 96% RA
GENERAL: well-appearing man. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with elevated JVP, at angle of jaw
CARDIAC: RR, normal S1, S2. No m/r/g. S3 audible at RUSB. ICD
pocket in upper L chest, no tenderness or hematoma
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds at bases, faint rales bibasilarly,
improved from yesterday
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no pedal edema, no femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
1cm raised erythematous lesion above sternum, appears like hive
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
Admission labs:
[**2126-3-11**] 05:20PM BLOOD WBC-7.0 RBC-4.51* Hgb-14.4 Hct-42.1
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.2 Plt Ct-234
[**2126-3-11**] 05:20PM BLOOD Neuts-61.3 Lymphs-32.3 Monos-4.4 Eos-1.5
Baso-0.5
[**2126-3-11**] 04:20PM BLOOD ESR-2
[**2126-3-11**] 05:20PM BLOOD Glucose-121* UreaN-21* Creat-1.1 Na-137
K-4.4 Cl-105 HCO3-21* AnGap-15
[**2126-3-11**] 05:20PM BLOOD ALT-149* AST-72* AlkPhos-89 TotBili-0.5
[**2126-3-11**] 05:20PM BLOOD Lipase-44
[**2126-3-11**] 05:20PM BLOOD cTropnT-<0.01
[**2126-3-12**] 03:30AM BLOOD CK-MB-4 cTropnT-<0.01
[**2126-3-11**] 05:20PM BLOOD proBNP-4767*
[**2126-3-12**] 03:30AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.1 Cholest-144
[**2126-3-11**] 04:20PM BLOOD D-Dimer-3019*
[**2126-3-12**] 05:05AM BLOOD %HbA1c-5.8 eAG-120
[**2126-3-12**] 03:30AM BLOOD Triglyc-74 HDL-36 CHOL/HD-4.0 LDLcalc-93
[**2126-3-11**] 04:20PM BLOOD TSH-3.5
[**2126-3-12**] 03:43AM BLOOD Type-ART pO2-94 pCO2-30* pH-7.44
calTCO2-21 Base XS--1
[**2126-3-11**] 07:19PM BLOOD Lactate-1.9
.
Discharge labs:
.
[**2126-3-18**] 07:10AM BLOOD WBC-7.5 RBC-4.76 Hgb-15.5 Hct-46.1 MCV-97
MCH-32.7* MCHC-33.8 RDW-14.5 Plt Ct-176
[**2126-3-18**] 07:10AM BLOOD Glucose-97 UreaN-23* Creat-1.2 Na-142
K-3.9 Cl-102 HCO3-28 AnGap-16
[**2126-3-18**] 07:10AM BLOOD ALT-128* AST-48* AlkPhos-91 TotBili-0.7
[**2126-3-18**] 07:10AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.6
[**2126-3-12**] 05:05AM BLOOD %HbA1c-5.8 eAG-120
[**2126-3-14**] 06:45AM BLOOD Triglyc-61 HDL-46 CHOL/HD-3.0 LDLcalc-81
LDLmeas-96
ECG [**3-11**]: Sinus tachycardia. Right superior axis. Low voltage.
Right bundle-branch block with prominent precordial Q waves in
leads V1-V4 with mild ST segment elevations. Consider pulmonary
disease, right ventricular hypertrophy, anterior wall myocardial
infarction. Low limb lead voltage.
.
Chest CTA [**3-11**]:
1. No evidence of pulmonary embolism.
2. Multilobar ground-glass opacities, similar in distribution to
the prior
examination with possible small increase in consolidation.
Findings
compatible with infectious process.
3. Moderate bilateral pleural effusions again seen.
4. Reflux of contrast into the IVC suggestive of right heart
failure which
can be further evaluated on echocardiogram. Non-specific left
ventricular
apex wall thickening can also be further evaluated on
echocardiogram.
.
Cardiac echo [**3-12**]: Normal left ventricular cavity size with
extensive regioanl systolic dysfunction suggestive of
multivessel CAD or other diffuse process. Apical mural left
ventricular thrombus. Right ventricular cavity enlargement with
free wall hypokinesis. Pulmonary artery systolic hypertension.
Mild-moderate mitral regurgitation. LVEF < 20%
.
Cardiac MRI [**3-13**]:
Impression:
1. Mildly enlarged left ventricular cavity size with severely
depressed left ventricular systolic function with hypokinesis of
the basal inferoseptum and basal to mid inferior and lateral
walls. The remaining walls are akinetic. The LVEF was severely
depressed at 21%. The effective forward LVEF was severely
depressed at 14%. Late gadolinium contrast-enhanced CMR images
demonstrating areas of hyperenhancement as described above. The
findings are consistent with a high likelihood of functional
recovery of the mid to basal inferoseptum, inferior and lateral
walls. There is a low likelihood of functional recovery of all
remaining segments.
2. Large laminated thrombus at left ventricular apex.
3. Focal apical aneurysm.
4. Normal right ventricular cavity size. The RVEF was severely
depressed at 17%.
5. Cardiac index is depressed at 1.8 l/min/m.2
6. Mild aortic regurgitation. Moderate to severe mitral
regurgitation. Mild pulmonic regurgitation.
7. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
8. Mild biatrial enlargement.
9. Normal coronary artery origins with no evidence of anomalous
coronary
arteries. In the setting of suboptimal image quality, there is a
proximal LAD severe stenosis and diffuse disease of the RCA. The
LMCA and proximal LCx are patent.
10. A note is made of a large right pleural effusion and
moderate left pleural effusion.
.
Cardiac cath [**3-14**]:
1. Selective coronary angigoraphy in this left dominant system
demonstrated two vessel disease. The LMCA had no
angiographically apparent disease. The LAD has a proximal total
occlusion. The very distal portion of the LAD filled via left to
left collaterals. The Cx had a 60% stenosis in the proximal
portion of the L-PDA. The RCA was a small non-dominant vessel
with no angiographically apparent disease.
2. Limited resting hemodynamics revealed elevated left and right
sided
filling pressures with an LVEDP of 27 mmHg and an RVEDP of 16
mmHg. There was moderate pulmonary artery hypertension with a
PASP of 58 mmHg. The cardiac index was depressed at 1.5
l/min/m2. The central aortic pressure was 113/87 mmHg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.
.
CXR [**3-16**]: IMPRESSION: AP chest compared to [**3-13**]:
Mild interstitial edema has improved, and small bilateral
pleural effusions and mild cardiomegaly are stable. New
transvenous right ventricular defibrillator lead is continuous
from the left axillary pacemaker terminating along the floor of
the right ventricle. No pneumothorax.
.

Brief Hospital Course:
49 year-old with PMH of HBV hepatitis on entecavir and
hypercholesterolemia who presented with 2 months history of
cough and SOB and recent progressive dyspnea and found to have
severe heart failure likely due to ischemic cardiomyopathy.
.
ACTIVE ISSUES:
--------------
.
# Ischemic cardiomyopathy / CHF: Patient had 2 month history of
cough and SOB, these were initially attributed to respiratory
infection and treated with two courses of azythromycin, without
improvement. On admission pnt appeared clinically and
radiographically fluid overloaded, was tachycardic, tachypneic
to 30-40 and desaturated to the high 80's on RA. He had elevated
BNP and neg trops X2. ECG showed right axis deviation, RBBB,
LAFB, and anteroseptal Q waves of unknown age. PE was ruled out
with negative LENI's and CTA. Echo showed severe LV hypokinesis
with EF < 20% and a mural thrombus as well as RV hypokinesis. Pt
was admitted to the ICU, treated with lasix and improvement of
symptoms. He was also initially started on captopril,
metoprolol, ASA 325mg, and heparin gtt (for LV thrombus).

Pt was transferred to the cardiology floor for further
management of CHF. Cardiac MR was done and showed hypokinesis of
the basal inferoseptum and basal to mid inferior and lateral
walls, which were thought to be viable. There was copmlete
akinesis of all other walls, which were non-viable. Cardiac
catheterization was done and showed 2 vessel disease with total
occlusion of proximal LAD and 60% of LCx in proximal region of
L-PDA. No stents were placed given distribution of stenosed
coronaries to non-viable areas of the myocardium. Pt has strong
family history of CAD and personal history of
hypercholeterolemia, which are the likely etiologies of his
ischemic disease; it is also possible that hepatitis B may be
contributing though this is rare. Pt was started on heparin gtt
bridge to coumadin for the LV thrombus and medical management of
his CHF with lisinopril 5mg, metoprolol 25mg daily, ASA 325mg,
statin 40mg, lasix 40mg daily. He was diuresed with IV lasix
during hospitalization, but still slightly overloaded at time of
discharge with elevated JVP and faint rales bilaterally. An ICD
was placed successfully and pocket appeared intact without
hematoma prior to discharge. Pt will follow-up in device clinic
1 week after discharge. He will have his INR and Chem 7 checked
with PCP this week, and has f/u with Dr. [**Last Name (STitle) **]. Pt will be
referred for ETT and outpatient cardiac rehabilitation.
.
# LV thrombus - seen on echo; pt was bridged to coumadin with
heparin drip. INR at time of discharge was 2.5 (goal [**3-14**]),
coumadin dose on discharge was 2mg qhs. As above, will have INR
monitored and coumadin adjusted accordingly by his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 58**].
.
# Hyperlipidemia: home pravastatin was increased to 40 mg qhs.
Goal LDL <70.
.
INACTIVE ISSUES:
----------------
# Hepatitis, HBV: pnt has known HBV infection with history of
hepatitis treated with entecavir for the past 6 months. AST/ALT
on this admission were up to 72/149 from 24/26 at baseline in
[**Month (only) 1096**] then trended down to ALT/AST 128/48 on discharge. Pt
was started on pravastatin 40mg qhs regardless of baseline
transaminitis, and will follow up with hepatology as an
outpatient (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]).
.
TRANSITION OF CARE:
------------------
# PCP [**Last Name (NamePattern4) 702**]:
- check INR, goal [**3-14**]
- check Chem 7 given discharged on lasix
.
# Cardiology follow-up:
- ICD device check
- medical management of heart failure and titration of lasix
- ETT (non-imaging) scheduled as outpatient as part of
[**Hospital 6848**] rehab work-up
.
# Hepatology follow-up:
- LFTs; discharged on pravastatin 40mg qhs


Medications on Admission:
multivitamin QD
Pravastatin 10mg QD
entecavir 0.5 mg tablet daily.
Aspirin daily was recommended but is not taking it


Discharge Medications:
1. entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 25 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*
5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
8. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have your Chem 7 panel and INR checked at Dr.[**Name (NI) 6849**]
office at your follow-up visit 2 days after discharge.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Ishemic cardiomyopathy
Acute CHF
.
Secondary:
Hepatitis B


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


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

You were admitted to [**Hospital1 18**] with heart failure. We did an
echocardiogram which showed decreased function of your heart and
an MRI which showed that some of areas of muscle in your heart
are not contracting the way they should. We did a cardiac
catheterization which showed that some of the arteries supplying
your heart have blockages. You did not have any stents placed
because the clogged arteries are supplying areas of the heart
that would not improve with stents. The blockages are likely
what caused your progressive heart failure.

You had an internal cardiac defibrillator placed in your chest
which will help stop irregular rhtyhms if they occur. Your heart
failure will be managed with medications (listed below). You
were started on a blood thinning medication for a thrombus
(clot) found in one of the [**Doctor Last Name 1754**] in your heart. You wlll have
many follow-up appointments in the next months, which are listed
below and very important to attend.

If your symptoms worsen, you gain water weight, have continued
worsening of your breathing, or have any shocks by your ICD, you
should come back to the hospital.

We have made the following changes to your medications:
- START lisinopril 5mg daily
- START pravastatin 40mg at nighttime
- START metoprolol XL 25mg daily
- START coumadin 2mg daily at 4pm
- START lasix 40mg daily
- START aspirin 325mg daily
- CONTINUE your entecavir 0.5mg daily

You will need to have your INR (level of blood thinner in your
blood) checked by your PCP [**Name Initial (PRE) **] few days after you leave the
hospital. Your goal level is [**3-14**] and your INR should be checked
regularly and coumadin dose adjusted accordingly.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

You should avoid driving until your ICD device has been tested
at device clinic. They will advise you when it will be safe for
you to resume. After your discharge, you should return to work
part-time for 1 week and afterwards as tolerated.

It was a pleasure taking care of you at the hospital. We wish
you a speedy recovery!

Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5080**], MD
Specialty: Internal Medicine
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Apartment Address(1) 6850**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 3329**]
We are working on a follow up appointment within the next [**2-11**]
days with Dr. [**Last Name (STitle) 58**] to have your INR checked. You will be
called at home with the appointment. If you have not heard or
have questions, please call the above number.

Department: CARDIAC SERVICES
When: THURSDAY [**2126-3-21**] at 1 PM
With: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2126-3-25**] at 2:00 PM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 6851**], MD
Specialty: Cardiology
Location: [**Hospital1 18**] - CARDIAC SERVICES
Address: [**Location (un) **], [**Hospital Ward Name **] 7, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
We are working on a follow up appointment within the next 3
weeks with Dr. [**Last Name (STitle) **]. You will be called at home with the
appointment. If you have not heard or have questions, please
call the above number.

Department: LIVER CENTER
When: WEDNESDAY [**2126-4-3**] at 4:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

You should also have an exercise stress test done after you are
discharged, this has been ordered and you will be called with
the date/time for the test.



Completed by:[**2126-3-18**]
{'Congestive heart failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Alkalosis,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Family history of ischemic heart disease'}


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

PRESENT ILLNESS: This is a 49 year-old male with a history of HBV hepatitis on
entecavir , hypercholesterolemia, family history of premature
CAD who presents with leg swelling and progressive SOB.
.
Worked up in late [**2125-12-10**] for week or so of cough, told he
had pneumonia by CXR, received 5 days of azyhtromycin w/o any
improvement in his cough. Got second CXR around [**12-24**]
findings had not cleared got another course of 5 days
Azithromycin which he finished 7 days prior to presentation
again w/o improvement in cough. During this period except for
cough complained of exertional dyspnea which has progressed
rapidly over the past week from 20 stairs to dyspnea at rest.
Admits to orthopnea two or more pillows, describes paroxysmal
cough at night but not PND. Noticed 11 lb weight gain over past
two months.  No nocturia. Denies chest pain. Two days prior to
admission had CT chest which showed diffuse bilateral
ground-glass infiltrates consistent with infectious process,
most likely atypical or viral pneumonia as well as bilateral
pleural effusions.  On day prior to admission noticed swelling
on right foot followed later by left foot swelling. Saw his PCP
who sent him to the ER.
.
  Does not recall recent febrile illness. Believes all his
symptoms started after  "overworked" himself in the gym around
Thanks Giving and had to spend a day in bed because of general
muscle soarness and chest pain. Patient has no history of HF or
coronary disease. Denies any recent travels. No contacts with
animals. No bites or stings. No contact with [**Name2 (NI) **] people. Was
vaccinated for Flu in early novemebr.
.
In the ED, admission vitals were: 99.9 121 134/91 20 100% on 4L
O2. He triggered for tachypnea 30-40 and dested to high 80's in
RA. Found to have right leg swelling, LENI was negative for DVT
as was CTA for PE. CTA did show multifocal ground glass
opacities and bil mod pleural effusions R>L essentially
unchanged from CT of 2 days prior. Labs showed unremarkable CBC,
chemistry remarkable for HCO3 = 21 with normal anion gap.
d-dimer was 3019. trop X 1 was negative. Patient was given 1
dose of ceftriaxone + levoflox in the ED (1900). His transfer
vitals were HR 112 BP 123/88 RR 34 Sat 95%4l
.
ROS:
+ nausea over past few days
- denies any fevers, nausea, vomiting, abdominal pain, diarrhea,
constipation, melena, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash.
.

MEDICAL HISTORY: - HBV hepatitis: biopsy [**7-/2125**] grade 2 inflammation and stage I
fibrosis on Entecavir with good response and normalized LFT's.
- Hypercholesterolemia
- bil varicocele surgery [**2108**]

MEDICATION ON ADMISSION: multivitamin QD
Pravastatin 10mg QD
entecavir 0.5 mg tablet daily.
Aspirin daily was recommended but is not taking it

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical:
.
Vitals: T: 97.5 BP: 136/95 HR: 107 RR: 37 O2Sat: 95% or 5L
GEN: tachypnic but not dyspnic, not in distress, completes full
sentenses, A+O x3, cooperative
HEENT: EOMI, PERRLA, sclera anicteric, MMM, OP Clear
NECK: No JVD but HJR is positive, carotid pulses brisk, no
bruits, no cervical lymphadenopathy, trachea midline
COR: limited by breath sounds but essentiall rapid RRR, no
M/G/R, normal S1 S2. Radial pulses +1
PULM: Lungs bil wet crackles to [**2-11**] hight of chest, no Wheezing,
reduced breath sounds and fremitus on bilateral bases,
precussion is symetrical and hypotympanic at bases
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No clubbing or cyanosis. Right calf > Left calf, no calf
tenderness, neg [**Last Name (un) **] sign, bil trace pre-tibial edema.
NEURO: grossly intact
SKIN: no stigmata of chronic liver disease
.
Discharge physical:
.
VS: Tm 98.4, 104/73-107/75, HR 89, RR 18, 96% RA
GENERAL: well-appearing man. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with elevated JVP, at angle of jaw
CARDIAC: RR, normal S1, S2. No m/r/g. S3 audible at RUSB. ICD
pocket in upper L chest, no tenderness or hematoma
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds at bases, faint rales bibasilarly,
improved from yesterday
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no pedal edema, no femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Small
1cm raised erythematous lesion above sternum, appears like hive
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Family Medical History:
Mother - CAD after age 55, CABG, DM type 2, HTN
Father - died at age 72, ESRD
3 brothers, 1 sister: sister with type 2 DM. Brother underwent
CABG at 50y.

SOCIAL HISTORY: Allergies:  NKDA
.
Social History:  Born in [**Location (un) 6847**], emmigrated to US at age 1y.
Accountant. Married + 1 daughter aged 15. ADL independent. No
etoh. No tobacco, no illicit. Monogamous sexuall relations with
wife. 

### Response:
{'Congestive heart failure, unspecified,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Alkalosis,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Family history of ischemic heart disease'}
