CHIEF COMPLAINT: S/p cardiac arrest

PRESENT ILLNESS: 46yoM with no cardiac history who was in the outpatient waiting
area of [**Hospital6 2910**] on [**2117-8-4**], waiting for his
wife who was having a procedure. He collapsed, had reported
seizure-like activity and urinary incontinence, then had
subsequent cardiac arrest, was intubated with ETT #7, received
1mg Epinephrine via ET tube, shocked once with return of
palpable femoral pulses within 15-30 secs after first shock, and
then given second 1mg Epinephrine. He began to move afterwards,
but pupils were noted to be "midsized and not responsive to
light." He was noted to have "spontaneous respiration" and then
transferred to ICU. Review of the strips was concerning for VFib
but ICU MD thinks maybe PEA.
.
Through his ICU course:
ABG there showed 7.31/37/477/19; normal BMP/Ca/Mg, WBC 14.9, Hct
44, Plts 269. He was given 1gm Mg and started on Propofol gtt. L
subclavian CVL was placed. ? infiltrate in RML on CXR for which
he is on Clindamycin; there was also concern for ? L clavicle
fracture that per discussion may be old (he is a steel worker
and was seeing a doctor and PT for L shoulder pain previous to
this). He is ventilated with 500 Tv, PEEP 5, FiO2 50%, and has
had no issues on the vent. Exam on admission significant for
pupils 2mm equal but not responsive to light, no doll's eyes,
decerebrate posturing, fine tremor in BUE's, irregular rhythm
with systolic murmur, wheezy lungs. Out of concern for the
"seizure" they have CT'd his head which was negative, and did an
EEG which did not show any seizure activity; per discussion they
did not feel that he actually had any seizure.
.
Per discussion with NEBH ICU physician, [**Name10 (NameIs) **] was Wellens pattern
in V3-4 with deep symmetric T waves. Echo significant for PASP
25-30, EF 55%, HK of mid to distal anterior free wall and
anteroseptum. Initial Trop on ICU admission was 2.5 but was
risen to 5 last night, and 11 this am. He has had no arrthymic
issues.
.
This am, he continues on Heparin gtt 1300 (with prolonged PTT),
Amiodarone 0.5mg/min gtt, and has been on 325 ASA, was Plavix
loaded 600 and 75 daily, Atorvastatin 80 daily, Lopressor 25 q6,
still intubated on Propofol. Just this am he has developed mild
hypoTN to the 90's for which he is being bolused with IVF's, no
pressors.   Plan is to transfer to CCU and have cardiac cath at
11a today with Dr. [**Last Name (STitle) **].
.
The pt's wife arrived and confirms he has no cardiac history, no
h/o HTN, HL, DM, FHx, but does actively smoke a few cigarettes
daily. His cardiac ROS was entirely negative before the event,
is very active without complaints of angina, DOE, syncope,
dizziness, swelling.
.
ROS otherwise with some musculoskeletal complaints; he had a
herniated disc and subsequent lower extremity radiculopathic
pain. She states he was doing PT, who wanted him to do some
weight lifting, and then for the past week was having L shoulder
pain (? L clavicle fx on CXR?). Also with some
depression/anxiety from being on disability and not being able
to work, otherwise all negative.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Former heavy smoker but has no cut down
to a few cigs per day, but no h/o HL/HTN/DM/FHx
2. CARDIAC HISTORY: No prior known cardiac disease
[**7-/2117**]: cardiac arrest requiring shock, ICU admission, echo
showing WMA concering for LAD lesion, transfer to [**Hospital1 18**] for cath

MEDICATION ON ADMISSION: - Trazadone 50 hs occasionally
- Neurontin 100 occasionally
- Flexeril prn

ALLERGIES: Statins-Hmg-Coa Reductase Inhibitors

PHYSICAL EXAM: Temp 100    p84   117/79   99%
Vent settings AC 500x14, PEEP5, and 100% FiO2
Average, not-obese M in no distress, diaphoretic, intubated, not
responding to verbal stimuli. PERRL from 4 -> 3, but no
oculovestibular reflex. No scleral icterus. Deferred mouth exam.
Internal jugular pulsations noted at 6cm above sternal notch at
30 deg, and prominent external jugulars noted, no Kussmaul's
sign.
CTAB on the anterolateral chest, looks synchronous with the vent
but occasionally coughing, with tan-white thick secretions
suctioned
RRR with no murmurs, gallops, strong S1/S2, bilateral palpable
DP and PT's
Abd overweight but not obese, soft, NT ND, benign
BLE's without edema, no chronic venous stasis changes.
Extremities are all warm, not mottling.
Neuro exam deferred

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
- Mother: Deceased when pt was 3yo from multiple sclerosis
- Father:  Alive at 78, healthy

SOCIAL HISTORY: Born in [**Country 4754**], has a brother in [**Name (NI) 4754**], married with 13 yo
son. Wife = [**Name (NI) **]. Disabled sheet metal worker, currently not
working due to L shoulder injury. Fairly active, walks his dog
daily. Has one brother in [**Name (NI) 4754**].
- Tobacco history: Wife and pt share 3 packs of cigs per week
- ETOH: Drank heavily but quit 14 yrs ago
- Illicit drugs:  None
Myocarditis, unspecified,Pneumonia due to Hemophilus influenzae [H. influenzae],Paroxysmal ventricular tachycardia,Acute systolic heart failure,Rhabdomyolysis,Anoxic brain damage,Delirium due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Tobacco use disorder,Long-term (current) use of anticoagulants,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,Other iatrogenic hypotension
Myocarditis NOS,H.influenzae pneumonia,Parox ventric tachycard,Ac systolic hrt failure,Rhabdomyolysis,Anoxic brain damage,Delirium d/t other cond,Hyperlipidemia NEC/NOS,Tobacco use disorder,Long-term use anticoagul,Adv eff antilipemics,Iatrogenc hypotnsion NEC
Admission Date:  [**2117-8-5**]              Discharge Date:   [**2117-8-14**]

Date of Birth:  [**2071-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Statins-Hmg-Coa Reductase Inhibitors

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
S/p cardiac arrest

Major Surgical or Invasive Procedure:
ICD placement
Cardiac catheterization


History of Present Illness:
46yoM with no cardiac history who was in the outpatient waiting
area of [**Hospital6 2910**] on [**2117-8-4**], waiting for his
wife who was having a procedure. He collapsed, had reported
seizure-like activity and urinary incontinence, then had
subsequent cardiac arrest, was intubated with ETT #7, received
1mg Epinephrine via ET tube, shocked once with return of
palpable femoral pulses within 15-30 secs after first shock, and
then given second 1mg Epinephrine. He began to move afterwards,
but pupils were noted to be "midsized and not responsive to
light." He was noted to have "spontaneous respiration" and then
transferred to ICU. Review of the strips was concerning for VFib
but ICU MD thinks maybe PEA.
.
Through his ICU course:
ABG there showed 7.31/37/477/19; normal BMP/Ca/Mg, WBC 14.9, Hct
44, Plts 269. He was given 1gm Mg and started on Propofol gtt. L
subclavian CVL was placed. ? infiltrate in RML on CXR for which
he is on Clindamycin; there was also concern for ? L clavicle
fracture that per discussion may be old (he is a steel worker
and was seeing a doctor and PT for L shoulder pain previous to
this). He is ventilated with 500 Tv, PEEP 5, FiO2 50%, and has
had no issues on the vent. Exam on admission significant for
pupils 2mm equal but not responsive to light, no doll's eyes,
decerebrate posturing, fine tremor in BUE's, irregular rhythm
with systolic murmur, wheezy lungs. Out of concern for the
"seizure" they have CT'd his head which was negative, and did an
EEG which did not show any seizure activity; per discussion they
did not feel that he actually had any seizure.
.
Per discussion with NEBH ICU physician, [**Name10 (NameIs) **] was Wellens pattern
in V3-4 with deep symmetric T waves. Echo significant for PASP
25-30, EF 55%, HK of mid to distal anterior free wall and
anteroseptum. Initial Trop on ICU admission was 2.5 but was
risen to 5 last night, and 11 this am. He has had no arrthymic
issues.
.
This am, he continues on Heparin gtt 1300 (with prolonged PTT),
Amiodarone 0.5mg/min gtt, and has been on 325 ASA, was Plavix
loaded 600 and 75 daily, Atorvastatin 80 daily, Lopressor 25 q6,
still intubated on Propofol. Just this am he has developed mild
hypoTN to the 90's for which he is being bolused with IVF's, no
pressors.   Plan is to transfer to CCU and have cardiac cath at
11a today with Dr. [**Last Name (STitle) **].
.
The pt's wife arrived and confirms he has no cardiac history, no
h/o HTN, HL, DM, FHx, but does actively smoke a few cigarettes
daily. His cardiac ROS was entirely negative before the event,
is very active without complaints of angina, DOE, syncope,
dizziness, swelling.
.
ROS otherwise with some musculoskeletal complaints; he had a
herniated disc and subsequent lower extremity radiculopathic
pain. She states he was doing PT, who wanted him to do some
weight lifting, and then for the past week was having L shoulder
pain (? L clavicle fx on CXR?). Also with some
depression/anxiety from being on disability and not being able
to work, otherwise all negative.
.


Past Medical History:
1. CARDIAC RISK FACTORS: Former heavy smoker but has no cut down
to a few cigs per day, but no h/o HL/HTN/DM/FHx
2. CARDIAC HISTORY: No prior known cardiac disease
[**7-/2117**]: cardiac arrest requiring shock, ICU admission, echo
showing WMA concering for LAD lesion, transfer to [**Hospital1 18**] for cath

3. OTHER PAST MEDICAL HISTORY:
- Herniated vertebral disc and radicular sxs
- L clavicle fracture incidentally noted on plain film
- EtOH 14 yrs ago
- ? depression/anxiety

Social History:
Born in [**Country 4754**], has a brother in [**Name (NI) 4754**], married with 13 yo
son. Wife = [**Name (NI) **]. Disabled sheet metal worker, currently not
working due to L shoulder injury. Fairly active, walks his dog
daily. Has one brother in [**Name (NI) 4754**].
- Tobacco history: Wife and pt share 3 packs of cigs per week
- ETOH: Drank heavily but quit 14 yrs ago
- Illicit drugs:  None


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
- Mother: Deceased when pt was 3yo from multiple sclerosis
- Father:  Alive at 78, healthy

Physical Exam:
Temp 100    p84   117/79   99%
Vent settings AC 500x14, PEEP5, and 100% FiO2
Average, not-obese M in no distress, diaphoretic, intubated, not
responding to verbal stimuli. PERRL from 4 -> 3, but no
oculovestibular reflex. No scleral icterus. Deferred mouth exam.
Internal jugular pulsations noted at 6cm above sternal notch at
30 deg, and prominent external jugulars noted, no Kussmaul's
sign.
CTAB on the anterolateral chest, looks synchronous with the vent
but occasionally coughing, with tan-white thick secretions
suctioned
RRR with no murmurs, gallops, strong S1/S2, bilateral palpable
DP and PT's
Abd overweight but not obese, soft, NT ND, benign
BLE's without edema, no chronic venous stasis changes.
Extremities are all warm, not mottling.
Neuro exam deferred

Pertinent Results:
[**2117-8-5**] 11:58PM   GLUCOSE-109* UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2117-8-5**] 11:58PM   CALCIUM-7.9* PHOSPHATE-0.8* MAGNESIUM-1.9
[**2117-8-5**] 08:17PM   TYPE-ART PO2-113* PCO2-46* PH-7.41 TOTAL
CO2-30 BASE XS-4
[**2117-8-5**] 08:17PM   LACTATE-0.9
[**2117-8-5**] 05:07PM   TIDAL VOL-500 O2-100 PO2-312* PCO2-42 PH-7.42
TOTAL CO2-28 BASE XS-3 AADO2-359 REQ O2-64 -ASSIST/CON
INTUBATED-INTUBATED
[**2117-8-5**] 05:07PM   GLUCOSE-105 LACTATE-0.8
[**2117-8-5**] 05:07PM   O2 SAT-98
[**2117-8-5**] 05:07PM   O2 SAT-98
[**2117-8-5**] 12:22PM   TYPE-ART PO2-268* PCO2-44 PH-7.40 TOTAL
CO2-28 BASE XS-2
[**2117-8-5**] 12:22PM   LACTATE-0.9
[**2117-8-5**] 12:22PM   O2 SAT-98
[**2117-8-5**] 12:22PM   freeCa-1.14
[**2117-8-5**] 11:46AM URINE  COLOR-AMB APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2117-8-5**] 11:46AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2117-8-5**] 11:35AM   GLUCOSE-107* UREA N-8 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-110* TOTAL CO2-26 ANION GAP-10
[**2117-8-5**] 11:35AM   estGFR-Using this
[**2117-8-5**] 11:35AM   ALT(SGPT)-42* AST(SGOT)-80* CK(CPK)-720* ALK
PHOS-51 TOT BILI-0.5
[**2117-8-5**] 11:35AM   CK-MB-19* MB INDX-2.6 cTropnT-0.89*
[**2117-8-5**] 11:35AM   CALCIUM-8.3* PHOSPHATE-1.9* MAGNESIUM-2.1
[**2117-8-5**] 11:35AM   WBC-12.6* RBC-4.05* HGB-13.5* HCT-37.1*
MCV-92 MCH-33.4* MCHC-36.4* RDW-13.7
[**2117-8-5**] 11:35AM   NEUTS-83.2* LYMPHS-12.2* MONOS-3.5 EOS-0.7
BASOS-0.4
[**2117-8-5**] 11:35AM   PLT COUNT-240
[**2117-8-5**] 11:35AM   PT-13.2 PTT-45.8* INR(PT)-1.1
.
.
ECG:
NEBH #1 = ~100 NSR, normal axis/intervals, elevations in
hyperacute TW's in V1-3, STD in V3-4, TWI in V5-6 and I/aVL;
possible Q wave in V1-3
NEBH #2 = worsening symmetric TWI in V4-6 and I/aVL and TWF
inferior leads
NEBH #3 = about the same but with STD inferior leads,
improvement in lateral TWI's
.
At NEBH on [**2117-8-4**]: normal LV size, wall thickness, HK of
mid-distal anterior and anteroseptal region. LV systolic fxn low
normal at 50-55%, RVSP = 23 + RAP
.
NEBH head CT non contrast without acute abnormality
.
Cardiac cath ([**2117-8-5**])
1. Selective coronary angiography of this left dominant system
demonstrated non-obstructive coronary artery disease.  The LMCA
and LAD
had minimal disease.  The LCx was a large vessel with mild
disease.  The
RCA was a small, non-dominant vessel.
2. Limited resting hemodynamics revealed elevated right- and
left-sided
filling pressures, with a mean RA pressure of 15 mmHg, and a
LVEDP of 24
mmHg.  The systemic arterial pressure was noted to be normal,
with a
central aortic pressure of 106/65, mean 82 mmHg.  No gradient
was seen
on careful pullback from the left ventricle to the aorta.
Cardiac
output and cardiac index likely significantly OVERestimated due
to FiO2
100%.
3. Left ventriculography revealed an estimated LVEF of 35%, and
was
notable for anteroapical hypokinesis.

FINAL DIAGNOSIS:
1. There appears to have been a probable LAD territory
infarct/thrombus
that spontaneously resolved with medical therapy.
2. Discussed with CCU Fellow/staff: wean off amiodarone, restart
heparin
gtt later, and continue ASA and Plavix.
3. IV Lasix for diuresis due to volume overload.
4. The patient will need a B-blocker and ACE-I once he is
extubated.
5. Transthoracic echocardiogram in the morning.
6. EP consult will likely be necessary.
.
Cardiac Cath [**2117-8-10**]
COMMENTS:
1) Selective coronary angiography of this left-dominant system
demonstrated no significant CAD. The LMCA and LAD had minimal
disease
throughout. The dominant LCX was a large caliber vessel with
minimal
disease. The non-dominant RCA was not injected.
2) Limited resting hemodynamics revealed mildly elevated
left-sided
filling pressures with an LVEDP of 21mmHg. There was normal
systemic
arterial pressure with a central aortic pressure of 133/84 with
a mean
of 86mmHg.
3) Left ventriculography revealed reduced systolic function with
an
estimated EF 40%. There were focal regional wall motion
abnormalities
with antero-apical and lateral hypokinesis.
4) Successful closure of the LFA with a 6F angioseal device.

FINAL DIAGNOSIS:
1. Possible vasospasm. Would continue NTG and calcium-channel
blockers
if BP tolerates (norvasc).
2. Rule out myocarditis by checking anti-myocardial antibodies
and viral
titers.
3. Resume heparin latertonight with no bolus.
4. Continue coumadin, ASA, clopidogrel (75mg/day x12mo).
5. Start ACEi (ramipril) if BP tolerates.
6. Successful closure of the LFA with a 6F angioseal device.
.
Echocardiogram
[**2117-8-6**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the distal
third of the ventricle.. The remaining segments contract
normally (LVEF = 40 %). No masses or thrombi are seen in the
left ventricle. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w Takotsubo cardiomyopathy or
mid-LAD lesion.
.
Echocardiogram
[**2117-8-10**]

The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with mid to distal
anterior, distal septal and apical akinesis and distal lateral
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
a small pericardial effusion. No right ventricular diastolic
collapse is seen. There is brief right atrial diastolic
collapse.

Compared with the prior study (images reviewed) of [**2117-8-6**],
the LVEF has decreased.
.
Cardiac MR
[**2117-8-9**] Pending at time of discharge


Brief Hospital Course:
46yoM with no known cardiac history who had witnessed cardiac
arrest, s/p resuscitation, with concern for LAD lesion, now
transferred from NEBH ICU to [**Hospital1 18**] CCU for cardiac
catheterization.

1. S/p cardiac arrest: It was unclear how long pt was down
before compressions started but he was in ventricular
fibrillation and after being shocked, he returned to sinus tach
within ten minutes.  Pt was not cooled because he was responsive
and moving around by the time he reached [**Hospital1 18**].  Also, cooling
protocol had not been initiated at OSH and by time he reached [**Hospital1 **]
he was out of the window to start cooling.  On arrival he was
tubed and sedated.  Pt was loaded with amio.  Over the next 24
hours, weaned off vent and pt responded appropriately.  He did
not have any other dangerous arrhythmias.  Etiology of vfib was
most likely secondary to ischemia.  [**Hospital1 **] and Echo were concerned
of mid-LAD lesion. Initially cardiac cath was performed and
showed that there appeared to have been a probable LAD territory
infarct/thrombus that spontaneously resolved with medical
therapy.  EP was consulted and performed EP study, placed single
chambe ICD with no complications.  A CMR was performed and
preliminarily suggested some scaring but final read is still
pending at time of discharge.  It was rec f/u with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] from cognitive neurology at time of d/c. He will need
repeat echo [**1-22**] wks after d/c.
.
Cardiomyopathy: Pt was previously healthy and now with depressed
LV function with apical hypokinesis.  Most likely secondary to
ischemia, but concern given coronary arteriogram did not show
any direct evidence occlusion.  Echo pattern was somewhat
consistent with takatsubo's.  Pt was started on metoprolol,
lisinopril and coumadin (apical akinesis) at time of discharge.
He was euvolemic without need for diuresis, so was not started
on lasix on discharge.
.
STE in lateral leads: Post cath, pt had persistent STE in
lateral leads and he was asymptomatic.  CE were relatively flat
with exception of CK (but pt had rhabdo).  Concern for coronary
vasospasm, so started on diltiazem drip, but this did not
resolve to elevations.  Pt was re-cathed, but coronaries were
clean.  Concern that these elevations are secondary to
myocarditis.  Labs were notable for mildly positive rheumatoid
factor, negative varicella and EBV.  At time of d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], viral
cx and antimyocardial ab were all pending.  Pt was discharged on
home dose of asa and started on plavix 75.
.
H. flu PNA: RML consilidation found post extubation.  Sputum cx
grew out h. flu and pt has not had prior vaccination.  He was
treated with azithromycin and ctx.  At time of d/c he had two
additional days of ctx so was started on cefpodoxime to finish
the abx course.
.
# Rhabdomyolysis: Thought to be secondary to amiodarone and
Atorvastatin. Pt's CKs rose to >11K but kidney function remained
normal throughout.  He also had mild transaminitis.  With
aggressive fluid resuscitation, CK's trended down and were wnl
by time of d/c.  Kidney fxn remained wnl as well.  Pt should
avoid atorvastatin and other lipophilic statins in the future.
.
# Delirium: After pt was extubated, he was persistently delerius
with difficulty following commands, signs of anterograde
amnesia, and difficulty with word finding.  He was also anxious
and paranoid, particularly at night.  Over course of
hospitalization his MS improved but was still mildly impaired at
time of d/c.  There is concern for hypoxic brain injury
secondary to cardiac arrest.  This will need to be worked up as
an outpatient and pt/family were encourage to follow up with
cognitive neurologist as above.
.
Transitional:
- needs f/u in device clinic one week after discharge
- [**Location (un) **] virus B AB, HSV 1 and 2 IGG, Myocardial Ab screen,
Parvovirus B19 Ab all pending at time of discharge
- follow up final read on cardiac MR

Medications on Admission:
- Trazadone 50 hs occasionally
- Neurontin 100 occasionally
- Flexeril prn

Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day
as needed for pain.
11. Outpatient Lab Work
on [**2117-8-16**] please Check a Chem 7, PT, PTT, INR and fax results
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 17382**]


Discharge Disposition:
Home

Discharge Diagnosis:
Myocarditis
Acute CHF exacerbation
pneumonia
Rhabdomyolysis
Delirium


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


Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 827**]. You were transfered here after experiencing a
cardiac arrest at [**Hospital6 2910**]. Further tests
have shown that you do not have blockages in your heart
arteries. We believe this cardiac event could have been due to a
viral infection at the present time. We placed a defibrillator
in your heart to help prevent any further cardiac arrests from
occuring. We started you on a medication called warfarin which
is a blood thinner. You will need to have your blood checked at
a lab on Monday [**2117-8-16**] and the results to be sent to Dr.[**Name (NI) 5452**]
office.  Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
goes up more than 3 lbs.

Changes to your medications:
STARTED:
Clopidogrel 75mg daily
Metoprolol Succinate 50 mg daily
Isosorbide Mononitrate 30 mg daily
Lisinopril 5 mg daily
Coumadin 5 mg daily

Please see below for follow up appointment information.

Followup Instructions:
We are working on a follow up appointment in Cardiology with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The office will contact you at home with an
appointment. If you have not heard within 2 business days or
have any questions please call [**Telephone/Fax (1) 7960**].

You also should follow up with the [**Hospital3 **] Cardiac Device
clinic in one week.  If you do not hear from then in the next
several days, please call  ([**Telephone/Fax (1) 2037**] to make this
appointment.

Please call our Cognitive Neurology department at [**Telephone/Fax (1) 1690**]
to book a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in
[**1-22**] weeks.
{'Myocarditis, unspecified,Pneumonia due to Hemophilus influenzae [H. influenzae],Paroxysmal ventricular tachycardia,Acute systolic heart failure,Rhabdomyolysis,Anoxic brain damage,Delirium due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Tobacco use disorder,Long-term (current) use of anticoagulants,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,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: S/p cardiac arrest

PRESENT ILLNESS: 46yoM with no cardiac history who was in the outpatient waiting
area of [**Hospital6 2910**] on [**2117-8-4**], waiting for his
wife who was having a procedure. He collapsed, had reported
seizure-like activity and urinary incontinence, then had
subsequent cardiac arrest, was intubated with ETT #7, received
1mg Epinephrine via ET tube, shocked once with return of
palpable femoral pulses within 15-30 secs after first shock, and
then given second 1mg Epinephrine. He began to move afterwards,
but pupils were noted to be "midsized and not responsive to
light." He was noted to have "spontaneous respiration" and then
transferred to ICU. Review of the strips was concerning for VFib
but ICU MD thinks maybe PEA.
.
Through his ICU course:
ABG there showed 7.31/37/477/19; normal BMP/Ca/Mg, WBC 14.9, Hct
44, Plts 269. He was given 1gm Mg and started on Propofol gtt. L
subclavian CVL was placed. ? infiltrate in RML on CXR for which
he is on Clindamycin; there was also concern for ? L clavicle
fracture that per discussion may be old (he is a steel worker
and was seeing a doctor and PT for L shoulder pain previous to
this). He is ventilated with 500 Tv, PEEP 5, FiO2 50%, and has
had no issues on the vent. Exam on admission significant for
pupils 2mm equal but not responsive to light, no doll's eyes,
decerebrate posturing, fine tremor in BUE's, irregular rhythm
with systolic murmur, wheezy lungs. Out of concern for the
"seizure" they have CT'd his head which was negative, and did an
EEG which did not show any seizure activity; per discussion they
did not feel that he actually had any seizure.
.
Per discussion with NEBH ICU physician, [**Name10 (NameIs) **] was Wellens pattern
in V3-4 with deep symmetric T waves. Echo significant for PASP
25-30, EF 55%, HK of mid to distal anterior free wall and
anteroseptum. Initial Trop on ICU admission was 2.5 but was
risen to 5 last night, and 11 this am. He has had no arrthymic
issues.
.
This am, he continues on Heparin gtt 1300 (with prolonged PTT),
Amiodarone 0.5mg/min gtt, and has been on 325 ASA, was Plavix
loaded 600 and 75 daily, Atorvastatin 80 daily, Lopressor 25 q6,
still intubated on Propofol. Just this am he has developed mild
hypoTN to the 90's for which he is being bolused with IVF's, no
pressors.   Plan is to transfer to CCU and have cardiac cath at
11a today with Dr. [**Last Name (STitle) **].
.
The pt's wife arrived and confirms he has no cardiac history, no
h/o HTN, HL, DM, FHx, but does actively smoke a few cigarettes
daily. His cardiac ROS was entirely negative before the event,
is very active without complaints of angina, DOE, syncope,
dizziness, swelling.
.
ROS otherwise with some musculoskeletal complaints; he had a
herniated disc and subsequent lower extremity radiculopathic
pain. She states he was doing PT, who wanted him to do some
weight lifting, and then for the past week was having L shoulder
pain (? L clavicle fx on CXR?). Also with some
depression/anxiety from being on disability and not being able
to work, otherwise all negative.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Former heavy smoker but has no cut down
to a few cigs per day, but no h/o HL/HTN/DM/FHx
2. CARDIAC HISTORY: No prior known cardiac disease
[**7-/2117**]: cardiac arrest requiring shock, ICU admission, echo
showing WMA concering for LAD lesion, transfer to [**Hospital1 18**] for cath

MEDICATION ON ADMISSION: - Trazadone 50 hs occasionally
- Neurontin 100 occasionally
- Flexeril prn

ALLERGIES: Statins-Hmg-Coa Reductase Inhibitors

PHYSICAL EXAM: Temp 100    p84   117/79   99%
Vent settings AC 500x14, PEEP5, and 100% FiO2
Average, not-obese M in no distress, diaphoretic, intubated, not
responding to verbal stimuli. PERRL from 4 -> 3, but no
oculovestibular reflex. No scleral icterus. Deferred mouth exam.
Internal jugular pulsations noted at 6cm above sternal notch at
30 deg, and prominent external jugulars noted, no Kussmaul's
sign.
CTAB on the anterolateral chest, looks synchronous with the vent
but occasionally coughing, with tan-white thick secretions
suctioned
RRR with no murmurs, gallops, strong S1/S2, bilateral palpable
DP and PT's
Abd overweight but not obese, soft, NT ND, benign
BLE's without edema, no chronic venous stasis changes.
Extremities are all warm, not mottling.
Neuro exam deferred

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
- Mother: Deceased when pt was 3yo from multiple sclerosis
- Father:  Alive at 78, healthy

SOCIAL HISTORY: Born in [**Country 4754**], has a brother in [**Name (NI) 4754**], married with 13 yo
son. Wife = [**Name (NI) **]. Disabled sheet metal worker, currently not
working due to L shoulder injury. Fairly active, walks his dog
daily. Has one brother in [**Name (NI) 4754**].
- Tobacco history: Wife and pt share 3 packs of cigs per week
- ETOH: Drank heavily but quit 14 yrs ago
- Illicit drugs:  None 

### Response:
{'Myocarditis, unspecified,Pneumonia due to Hemophilus influenzae [H. influenzae],Paroxysmal ventricular tachycardia,Acute systolic heart failure,Rhabdomyolysis,Anoxic brain damage,Delirium due to conditions classified elsewhere,Other and unspecified hyperlipidemia,Tobacco use disorder,Long-term (current) use of anticoagulants,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,Other iatrogenic hypotension'}
