CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 45yo non-smoking Male with family history of CAD who present to
OSH with progressive sob over one month.  He reports antecedent
"flu" like symptoms including congestion, headache,
non-productive cough.  The symptoms resolved after two weeks at
which point he noticed dyspnea on exertion and continued
non-productive cough.  Symptoms are exacerbated at night when he
lies down and relieved by sitting up.  Pt admits to PND but
denies orthopnea - stable 1 pillow.  Pt denies chest pain, but
admits to some reproducible chest discomfort.  He also denies le
swelling (thought he was just getting flabby).  Although the
patient is not very active, he reports he could walk many miles
and walk up 1 flight of stairs (and maybe two flights with some
strain) without difficulty 6 months ago.  Now though he admits
he can not walk up a flight of stairs without shortness of
breath.
   The patient presented to Metowest ED with a BP of 194/138
with pulse 110 and 2+ piting edema.  ECG was read as NSR with
LVH and non-specific anterior T and ST abnormalities.  CXR
showed curly B-lines with redistribution consistent with CHF.
BNP was 1690, CK 74, troponin 0.05.  He was given 40mg IV lasix
x1, 1 inch nitro past without change in his BP.  Cardiology on
call recommended IV hydralazine, however this was never given as
they had difficulty obtaining hydralazine from the pharmacy at
the time.  He was subsequently started on nitro gtt and
transferred to [**Hospital1 18**] ED.
   At [**Hospital1 18**], the patient received ASA x1, SL NTG and metoprolol
5mg IV x1.  He was then started back on the nitro gtt and
admitted to the CCU.

MEDICAL HISTORY: None (Has not seen a doctor since the 80s)

MEDICATION ON ADMISSION: As outpatient:
1. ASA 325mg once daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:
On admision to ED: T: 97.7  HR: 72     BP: 294/131    RR: 20
SaO2: 95% on RA
At time of transfer: T: 97.2  HR: 66   BP: 184/96     RR: 22
SaO2: 96% RA
Gen: middle aged caucasian male lying in bed asleep but easily
arousable to verbal stimuli.  Conversing fluently in full
sentences.  NAD
HEENT: EOMI, anicteric, PERRL 2mm bilaterally
Left fundoscopic exam: optic disc difficult to appreciate, no
obvious nicking of vessels, or flame hemorrhage.
Right fundoscopic exam: difficult to assess due to glare.
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Ext: trace to +1 pitting edema
Neuro: CN II-XII grossly intact

FAMILY HISTORY: Father: 1st MI at 55, CA
Mother: [**Name (NI) 11964**]
Pt is the youngest of 9 children.
Brother: CABG at age 50
Brother: CVA ?age
Brother: gall bladder, pancreatitis

SOCIAL HISTORY: Pt is a retired former desk worker.  He has worked at med
records at [**Hospital1 **], desk clert at motel 6, etc in past.  He
admits to occasional drug use but denies smoking, illicit drug
use.
Coronary atherosclerosis of native coronary artery,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial flutter,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute posthemorrhagic anemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disorder of kidney and ureter,Family history of ischemic heart disease
Crnry athrscl natve vssl,Iatrogen CV infarc/hmrhg,Atrial flutter,CHF NOS,Pleural effusion NOS,Ac posthemorrhag anemia,Hypertension NOS,DMII wo cmp nt st uncntr,Renal & ureteral dis NOS,Fam hx-ischem heart dis
Admission Date:  [**2101-2-15**]              Discharge Date:   [**2101-3-3**]

Date of Birth:  [**2055-5-18**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
CABGx6
Cardiac Catheterization with IntrAortic Balloon pump


History of Present Illness:
45yo non-smoking Male with family history of CAD who present to
OSH with progressive sob over one month.  He reports antecedent
"flu" like symptoms including congestion, headache,
non-productive cough.  The symptoms resolved after two weeks at
which point he noticed dyspnea on exertion and continued
non-productive cough.  Symptoms are exacerbated at night when he
lies down and relieved by sitting up.  Pt admits to PND but
denies orthopnea - stable 1 pillow.  Pt denies chest pain, but
admits to some reproducible chest discomfort.  He also denies le
swelling (thought he was just getting flabby).  Although the
patient is not very active, he reports he could walk many miles
and walk up 1 flight of stairs (and maybe two flights with some
strain) without difficulty 6 months ago.  Now though he admits
he can not walk up a flight of stairs without shortness of
breath.
   The patient presented to Metowest ED with a BP of 194/138
with pulse 110 and 2+ piting edema.  ECG was read as NSR with
LVH and non-specific anterior T and ST abnormalities.  CXR
showed curly B-lines with redistribution consistent with CHF.
BNP was 1690, CK 74, troponin 0.05.  He was given 40mg IV lasix
x1, 1 inch nitro past without change in his BP.  Cardiology on
call recommended IV hydralazine, however this was never given as
they had difficulty obtaining hydralazine from the pharmacy at
the time.  He was subsequently started on nitro gtt and
transferred to [**Hospital1 18**] ED.
   At [**Hospital1 18**], the patient received ASA x1, SL NTG and metoprolol
5mg IV x1.  He was then started back on the nitro gtt and
admitted to the CCU.

Past Medical History:
None (Has not seen a doctor since the 80s)

Social History:
Pt is a retired former desk worker.  He has worked at med
records at [**Hospital1 **], desk clert at motel 6, etc in past.  He
admits to occasional drug use but denies smoking, illicit drug
use.

Family History:
Father: 1st MI at 55, CA
Mother: [**Name (NI) 11964**]
Pt is the youngest of 9 children.
Brother: CABG at age 50
Brother: CVA ?age
Brother: gall bladder, pancreatitis


Physical Exam:
VS:
On admision to ED: T: 97.7  HR: 72     BP: 294/131    RR: 20
SaO2: 95% on RA
At time of transfer: T: 97.2  HR: 66   BP: 184/96     RR: 22
SaO2: 96% RA
Gen: middle aged caucasian male lying in bed asleep but easily
arousable to verbal stimuli.  Conversing fluently in full
sentences.  NAD
HEENT: EOMI, anicteric, PERRL 2mm bilaterally
Left fundoscopic exam: optic disc difficult to appreciate, no
obvious nicking of vessels, or flame hemorrhage.
Right fundoscopic exam: difficult to assess due to glare.
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Ext: trace to +1 pitting edema
Neuro: CN II-XII grossly intact

Pertinent Results:
[**2101-2-15**] 02:55AM   GLUCOSE-194* UREA N-32* CREAT-1.6* SODIUM-138
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
[**2101-2-15**] 02:55AM   WBC-10.3 RBC-5.12 HGB-14.2 HCT-42.0 MCV-82
MCH-27.7 MCHC-33.7 RDW-14.1
[**2101-2-15**] 02:55AM   NEUTS-72.7* LYMPHS-21.7 MONOS-3.8 EOS-1.6
BASOS-0.2
[**2101-2-15**] 02:55AM   PLT COUNT-206
[**2101-2-15**] 02:55AM   PT-13.4 PTT-22.6 INR(PT)-1.1
[**2101-2-15**] 02:55AM   CK(CPK)-63
[**2101-2-15**] 02:55AM   CK-MB-NotDone
[**2101-2-15**] 02:55AM   cTropnT-0.05*

.
[**2101-2-15**] CXR: Portable AP, min rotation, good inspiration and
penetration.  No air under diaphragm, no obvious bony fractures,
possible vascular redistribution.
.
[**2101-2-15**] ECG: NSR at 70, Nml axis, widened P wave, TWI in I, aVL,
II, V2-V6, 0.5mm ST depression in I, 0.25mm ST depression in L,
0.5mm ST elevation in V1, V2, LVH.
.
[**2101-2-17**] ETT-MIBI:
"INTERPRETATION: 45 yo man was referred to evaluate his
shortness of
breath. The patient completed 3 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
representing
a very poor functional exercise tolerance. The exercise test was
stopped
secondary to early-onset, progressive and marked shortness of
breath at
peak exercise. In the setting of the marked shortness of breath,
a drop
in systolic blood pressure was noted from baseline; 140/90 to
120/88
(taken twice). No chest, back, neck or arm discomforts were
reported
during the procedure. No lightheadedness of pre-syncopal
symptoms were
reported. In the presence of baseline LVH, the ECG is
uninterpretable.
The rhythm was sinus with no ectopy noted. As noted, an
asymptomatic
hypotensive response to exercise was noted.

IMPRESSION: Poor functional exercise tolerance limited by marked

dyspnea disproportionate to the level of exercise. Asymptomatic
hypotensive blood pressure response to exercise. No typical
anginal
symptoms with an uninterpretable ECG. Nuclear report sent
separatately."
.
.
"HISTORY: the new diagnosis of diabetes, hypercholesterolemia
and new onset congestive heart failure.

SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Exercise protocol: [**Doctor First Name **]
Resting heart rate: 61
Resting blood pressure: 140/98
Exercise duration: 3 minutes
Peak heart rate: 92
Percent maximum predicted heart rate obtained: 53%
Blood pressure at peak exercise: 120/88
Symptoms during exercise: progressive early onset shortness of
breath
Reason exercise terminated: progressive shortness of breath and
drop in systolic blood pressure
ECG findings: uninterpretable

INTERPRETATION:
Imaging Protocol: Gated SPECT
Resting perfusion images were obtained with Tl-201.
Tracer was injected 15 minutes prior to obtaining the resting
images. Exercise
images were obtained with Tc-[**Age over 90 **]m sestamibi.
This study was interpreted using the 17-segment myocardial
perfusion model.

The image quality is good.

Left ventricular cavity size is enlarged with a calculated
volume at end
diastole of 244 cc.

Gated images reveal severe global hypokinesis.
The calculated left ventricular ejection fraction is 27%.

There are no fixed or reversible perfusion defects.

IMPRESSION: Normal myocardial perfusion at the level of exercise
achieved with left ventricular dilatation, global hypokinesis,
and calculated ejection fraction of 27%."
.
.
[**2101-2-17**] Cardiac Catheterization:
"INDICATIONS FOR CATHETERIZATION:
Positive stress test, ongoing chest pain.

PROCEDURE:
Coronary Angiography: was performed in multiple projections
using a 6
French JL4, a 6 French JR4 catheter, and a 6 F AR2, with manual
contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a 8F 40 cc wire guided catheter, inserted via the
right
femoral artery.
Conscious Sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.

HEMODYNAMICS RESULTS BODY SURFACE AREA:  2.32 m2
  HEMOGLOBIN: 13.9 gms %
  FICK
**PRESSURES
LEFT VENTRICLE {s/ed} 147/30
AORTA {s/d/m} 147/108/119
**CARDIAC OUTPUT
HEART RATE {beats/min} 65
RHYTHM SINUS

**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA   NORMAL
2) MID RCA   NORMAL
2A) ACUTE MARGINAL   NORMAL
3) DISTAL RCA   NORMAL

**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN   NORMAL
6) PROXIMAL LAD   DISCRETE 80
6A) SEPTAL-1   NORMAL
7) MID-LAD   NORMAL
8) DISTAL LAD   DISCRETE 80
9) DIAGONAL-1   NORMAL
11) INTERMEDIUS   DISCRETE 80
12) PROXIMAL CX   DISCRETE 70
13) MID CX   NORMAL
13A) DISTAL CX   NORMAL
14) OBTUSE MARGINAL-1   DISCRETE 99
17) LEFT PDA   DISCRETE 90
17A) POSTERIOR LV   NORMAL


TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 49 minutes.
Arterial time = 46 minutes.
Fluoro time = 17.9 minutes.
Contrast:
          Non-ionic low osmolar (isovue, optiray...), vol 120
ml, Indications - Hemodynamic
Premedications:
          ASA 325 mg P.O.
Anesthesia:
          1% Lidocaine subq.
Anticoagulation:
          Heparin 4000 units IV
Other medication:
          Fentanyl 50 mcg IV
          Heparin drip 1000 u/hr IV ggt
          Nitroglycerine 140 mcg iv ggt
          Versed 1 mg IV
Cardiac Cath Supplies Used:
          8F ARROW, ULTRA 8, 40CC
          200CC MALLINCRODT, OPTIRAY 200CC


COMMENTS:
1. Selective coronary angiography revealed a left dominant
system with
an anomalous takeoff of the LCX from the right cusp. The LAD had
a 80%
stenosis at the origin and a 80% very distal stenosis. There was
a large
trifurcating ramus with 80% stenoses in all three branches. The
LCX was
a large ectopic vessel coming off the right cusp with a 70%
proximal
stenosis. The OM1 was intermittently occluded during the
procedure, but
had a 99% stenosis at the end of the case. The PDA had a 90%
stenosis at
the origin. There was also a large posterolateral branch. The
RCA was a
small nondominant vessel with no significant disease.
2. Limited hemodynamics showed elevated LV filling pressures
with an
LVEDP of 30 mm Hg. There was no gradient across the aortic valve
on
pullback.
3. 8F 40 cc IABP was placed to help stablize the patient prior
to CABG
tomorrow.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Anomalous takeoff the the LCX.
3. Elevated left sided filling pressures."
.
.


Brief Hospital Course:
A/P: 45yo Male with no signficant PMH who presents with
hypertensive urgency.
.
1.  CV:
A). CAD: The patient was initially admitted with hypertensive
urgency and given his LVH on ECG, the HTN was thought to be most
likely chronic. The patient was eventually placed on 4 oral
medication. The pt required metoprolol 100mg TID, lisinopril
40mg once daily, HCTZ 25mg once daily, and Norvasc 10mg once
daily to attain appropriate SBP control.  As the patient had
several risk factors for CAD including family history of early
CAD, HTN, DM and hypercholesterolemia, he was taken for ETT-MIBI
for further risk stratification.  Pt was found to have a
hypotensive response to exercise on ETT with transient ischemic
dilation and global hypokinesis with EF of 27% on MIBI. Almost
immediately after the ETT-MIBI, the patient developed an episode
of CP with new ST depressions in V3-V6 with deeper TWI in those
leads. At the time, the patient was found to be markedly
hypertensive with SBP in 170s. He was started on heparin gtt and
nitro gtt and sent for emergent cardiac catheterization.  The
cardiac catheterization demonstrated 3VD with anomalous take off
of LCx (off Right cusp). 80% LAD at origin and distal, large
Ramus with 80% stenosis in all three branches, 70% proximal LCx,
intermittently occluded OM1. IABP was placed and the patient was
scheduled for CABG in the AM.  The patient was cont. on the
nitro gtt, and beta blocker, however the ACEI was held pending
surgery and the CCB was held given the ongoing ACS.  Please see
the additional d/c summary from cardiothoracic surgery team for
further details of his intra-op and post op course.
.
B). Pump: The patient had signs and sx of mild heart failure
with unknown EF.  A TTE showed normal to low EF of 50% but the
MIBI demonstrated an EF of 27%. As he had clinical signs of mild
CHF on admission, he was gently diruesed.  The etiology of the
CHF was unclear, however it was most likely multifactorial with
contribution from HTN, ischemia, and possibly even viral.  In
the cath lab, he was given an IABP for additional inotropic
support.
.
C). Rhythm: The patient was in NSR with LVH and ?strain pattern.
 He was monitor on tele in the CCU without events.
.
2. Renal: Pt with creatinine of 1.6 on admission to ED. It was
difficult to assess whether this was acute vs chronic -
secondary to recent devlopment of CHF versus chronic HTN. In
addition, the patient has some proteinuria (30 proteins in
urine) which was more suggestive of chronic HTN as the cause.
The creatinine did improve somewhat with improved cardiac
function and gentle diuresis. Recommend consideration of renal
US to assess for hydro and signs of chronic kidney disease and
if necessary MRA for renal artery stenosis as cause of both CRI
and HTN as outpatient.
.
3.  DM: The patient does not carry a diagnosis of DM, however a
glucose of 194 on admission chem 7 was concerning.  A Hgb A1c
returned with a value of 8 confirming our diagnosis of diabetes.
 He was started on HISS with goal to obtain tight glycemic
control in the setting of ACS and impending surgery. .
.
4.  FEN: diabetic, heart friendly low salt diet, replete lytes
.
5.  PPx: The patient was continued on heparin sub Q TID or
heparin gtt for DVT prophylaxis during the duration of the
admission.  He was also started on colace and senna for bowel
regimen as well.
.
6.  Code: full code
.
7.  The patient was sent to OR urgently for CABG, please see the
associated d/c summary from CT surgery team for the remainder of
the hospital course for this admission.


Medications on Admission:
As outpatient:
1. ASA 325mg once daily

Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Warfarin Sodium 4 mg Tablet Sig: Four (4) Tablet PO at
bedtime: check PT/INR once daily untl INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
18. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: dose per sliding scale.
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q12H (every 12 hours) for 7 days.
Disp:*16 gm* Refills:*0*
20. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gm
Intravenous  Q8H (every 8 hours) for 7 days.
Disp:*5 gm* Refills:*0*
21. Mycostatin 100,000 unit/g Powder Sig: One (1)  Topical
[**Hospital1 **]/PRN.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
CAD - s/p Cardiac Catheterization, s/p CABG x 6
Post-Operative Atrial Fibrillation, Atrial Flutter
HTN
Embolic Stroke
DM II (new diagnosis)
Blood loss anemia
Pleural Effusions


Discharge Condition:
Fair

Discharge Instructions:
No lifting over 10 pounds for 4-6 weeks.
Call if you experience worsening chest pain, shortness of
breath, or increasing redness/drainage from the wound.
You may shower, but no tub baths/swimming.


Followup Instructions:
-with Dr. [**Last Name (STitle) **] in [**Hospital **] clinic in [**11-21**] months ([**Telephone/Fax (1) 8793**]

-with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology) in 1 month ([**Telephone/Fax (1) 7437**]

[**Hospital 60717**] [**Hospital **] clinic ([**Telephone/Fax (1) 17484**] (Dr. [**Last Name (STitle) 174**] if possible)upon
discharge from rehab

-with neurology/stroke clinic in 2 weeks ([**Telephone/Fax (1) 2528**]

-Call Dr.[**Name (NI) 27686**] office and set up a follow up appointment
for mid [**Month (only) **] (in 4 weeks)




Completed by:[**2101-3-20**]

Admission Date: [**2101-2-15**]        Discharge Date: [**2101-3-3**]

Date of Birth:  [**2055-5-18**]        Sex:  M

Service:  CSU


ADMISSION DIAGNOSES:  Hypertensive urgency.

Rule out myocardial infarction.

DISCHARGE DIAGNOSES:  Multivessel coronary artery disease -
status post cardiac catheterization, status post coronary
artery bypass grafting x6.

Postoperative atrial fibrillation, atrial flutter.

Hypertension.

Diabetes mellitus type 2 (new diagnosis).

Embolic cerebrovascular accident.

Blood loss anemia.

Pleural effusions.

Question of pneumonia versus aspiration pneumonia.

ADMISSION HISTORY AND PHYSICAL:  Mr. [**Known lastname **] was thought to be
a generally healthy 45-year-old gentleman who had not seen a
physician in over 20 years who presented to the ER with
complaints of increasing shortness of breath and was found at
[**Hospital1 **] to have significantly increased blood pressure to
180s-190s. He was transferred to the [**Hospital1 190**] for further workup. He was initially admitted
to the medical service for management of his hypertensive
urgency and further workup of his dyspnea.

On exam, he was afebrile. His pulse was in the 60s. His blood
pressure was between 180 and 190 systolic with a diastolic of
95-100. He is otherwise breathing at a rate of 22 and
saturating 96% on room air. His exam was notable for a few
crackles at the bases of his lungs. But otherwise, his heart
was regular and otherwise there was no rub. He had trace
edema in his extremities. His exam is otherwise essentially
unremarkable.

His admission white count was 10.3 with a hematocrit of 42.
His BUN and creatinine were notably 32 and 1.6 and his blood
sugar was 194. His CK, CK-MB, and troponins were normal.
Notably, a chest x-ray showed no evidence of failure. But his
EKG showed some T-wave inversion in the lateral leads. He was
therefore admitted to the medical service for rule out MI and
further cardiac workup.

HOSPITAL COURSE:  Patient was admitted as noted above. His
cardiac enzymes were negative for evidencing any myocardial
infarction. But given his significant risk factors, it is
felt that he needed to be worked up somewhat further. He
continued to have significant elevations of his blood
pressure which were controlled with combination of various
nitrate drips along with beta-blockade, diuretics, and ACE
inhibitors.

During this time, he was monitored in the cardiac intensive
care unit. He subsequently underwent noninvasive cardiac
stress testing, which did not show any evidence of ischemia;
but he was quite symptomatic during this time. Therefore, he
subsequently underwent cardiac catheterization which in fact
showed 3 vessel coronary artery disease with elevated left-
sided filling pressures.

His cardiac catheterization from [**2101-2-17**] showed that
he had a left dominant system with a 90% stenosis at the
origin of the left anterior descending with an 80% distal
lesion. His left circumflex had a large trifurcating ramus
with an 80% lesion in all 3 branches and 99% OM-1 lesion,
which was intermittently occluded, and 90% lesion of the PDA.
He had an intra-aortic balloon pump placed periprocedural and
urgent cardiac surgical consultation was obtained at which
time it is felt that patient would most benefit from coronary
artery bypass grafting.

He was taken to the operating room on [**2101-2-18**] at which
time he had a 6-vessel coronary artery bypass grafting with
LIMA to LAD, SVG to PDA to OM, SVG to IR to IR, SVG to IR.
Cardiopulmonary bypass time was 97 minutes and the cross-
clamp time was 68 minutes. There were no intraoperative
complications. Patient was transferred to the cardiac surgery
recovery unit postoperatively intubated on Levophed,
propofol, insulin, and milrinone drips.

Postoperatively, patient's blood pressures were quite labile
requiring vigilant monitoring of his hemodynamic medications.
But we were able to stabilize his blood pressure and his
cardiac index. We removed his intra-aortic balloon pump on
postoperative day 2 without complication. He was difficult to
extubate initially secondary not to problems with
oxygenation, but problems with mentation. We minimized his
sedation and narcotics in order to allow him to clear, but
subsequently quite slow in clearing.

It was noted on postoperative day 4, the patient was having
significantly decreased movement of his left side and also
given his change in mentation, that there is concern that
neurologic process might be occurring. We attempted to rule
out any infectious and metabolic etiologies, which were
negative. Subsequently, a stat CT scan of the head showed no
evidence of major infarction, or mass, or hemorrhage. But a
neurology consultation was obtained, who recommended MR of
the brain, which showed diffuse multiple punctate infarcts
involving the white matter in both cerebral hemispheres, in
the frontal and parietal lobes, and also small left acute
cerebellar infarct. These were consistent with microembolic
CVA, which likely occurred periprocedural.

He was started on Plavix and this statin. But it is felt by
neurology that he should not be anticoagulated at this time
as there is no further source of emboli. His cardiac status
was also compromised postoperatively by multiple episodes of
atrial flutter, which subsequently degenerated to atrial
fibrillation. Electrophysiology service was consulted for
assistance in management of this and initially had the
patient scheduled for ablation of his A-flutter. But as it
converted to atrial fibrillation, it is felt he should be
maintained on Coumadin and amiodarone. Will subsequently
follow up with electrophysiology as an outpatient.

He otherwise never evidenced any sort of ischemia or
congestive heart failure postoperatively, and had good
results from his surgery. Patient notably came in
hyperglycemic. Workup included a HBA1C which was found to be
8.3, which was consistent with history of diabetes mellitus.
He was seen by [**Hospital **] Clinic who started him on a regimen of
oral medications and insulin and continued to follow him
throughout his hospitalization. By the time of his discharge,
his blood sugars were well controlled on combination of oral
medications and glargine at night along with an insulin-
sliding scale.

Notably, patient's white blood cell count was elevated early
in the postoperative period on postoperative day 3 along with
low grade temperatures with occasional fevers to 101. He was
pancultured at that time and his urine and blood cultures
never evidenced any growth. His central line was changed and
removed. But the catheter tip also never evidenced any
growth. His sputum cultures consistently grew out
oropharyngeal flora and his chest x-ray showed what was left
pleural effusion process, but could not definitively rule out
a pneumonia. He was therefore treated empirically with
vancomycin and Zosyn for possible pneumonia versus aspiration
pneumonia. Was started on a 2-week course of this, which he
will finish at rehab.

By the time of his discharge, he had been afebrile with a
white blood cell count, which had been trending down. As
noted above, the patient was anticoagulated with Coumadin for
his atrial fibrillation with a Heparin drip used as a bridge.
He did have a formal swallow evaluation which showed that he
was able to take liquids and solids without difficulty or
risk for aspiration.

By postoperative day 13, patient was alert and mentating
well. He was moving all his extremities with a slight deficit
in the left upper and left lower extremity and the strength
each [**1-22**]. His lungs were essentially clear bilaterally. He
was in a sinus rhythm. His abdomen was otherwise soft. His
wound was healing well without significant drainage, and he
only had trace edema in the lower extremities. His white
blood cell count was 15.5 with a hematocrit of 29.5. His
platelets are 366. His INR was 1.5. His BUN and creatinine
were 27 and 1.6. His weight was 115 kg with a preoperative
weight of 107 kg.

As he had been afebrile, hemodynamically normal, and was just
receiving physical and occupational therapy, it is felt that
he can be discharged to rehabilitation in fair condition.

He was discharged to rehab on the following medications:
Lopressor 100 mg p.o. t.i.d., Lasix 20 mg p.o. q.12h.,
potassium chloride 20 mEq p.o. q.12h., Colace 100 mg p.o.
b.i.d., aspirin 82 mg p.o. once daily, Percocet 5-325 take 1-
2 tablets every 4-6 hours as needed for pain, Plavix 75 mg
p.o. once daily, Lipitor 10 mg p.o. once daily, Protonix 40
mg p.o. once daily, Norvasc 10 mg p.o. once daily, Glipizide
5 mg p.o. b.i.d., amiodarone 200 mg p.o. t.i.d. for 4 weeks,
Ambien 5 mg p.o. nightly as needed, Flomax 0.4 mg p.o.
nightly, lisinopril 10 mg p.o. once daily, Coumadin 4 mg p.o.
nightly with continued followup of his PT/INR for a goal of
2.0-2.5, insulin glargine 9 units subcutaneously nightly,
Humalog insulin-sliding scale, vancomycin 1 gram IV q.12h.
for 7 more days for a total course of 2 weeks, Zosyn 4.5
grams IV q.8h. for 7 more days for a total of 2 weeks.

He was to followup with Dr. [**Last Name (STitle) **] of electrophysiology in
clinic in 1 month and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of cardiology in 1
month. He is to followup with the [**Hospital **] Clinic with Dr.
[**Last Name (STitle) 174**] if possible upon discharge from rehab for management of
his blood sugars, and he was to followup with the Neurology
[**Hospital 4038**] Clinic in 2 weeks and Dr.[**Name (NI) 27686**] office in 4
weeks.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]

Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D:  [**2101-3-3**] 10:46:03
T:  [**2101-3-3**] 11:30:36
Job#:  [**Job Number 60716**]
{'Coronary atherosclerosis of native coronary artery,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial flutter,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute posthemorrhagic anemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disorder of kidney and ureter,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: 45yo non-smoking Male with family history of CAD who present to
OSH with progressive sob over one month.  He reports antecedent
"flu" like symptoms including congestion, headache,
non-productive cough.  The symptoms resolved after two weeks at
which point he noticed dyspnea on exertion and continued
non-productive cough.  Symptoms are exacerbated at night when he
lies down and relieved by sitting up.  Pt admits to PND but
denies orthopnea - stable 1 pillow.  Pt denies chest pain, but
admits to some reproducible chest discomfort.  He also denies le
swelling (thought he was just getting flabby).  Although the
patient is not very active, he reports he could walk many miles
and walk up 1 flight of stairs (and maybe two flights with some
strain) without difficulty 6 months ago.  Now though he admits
he can not walk up a flight of stairs without shortness of
breath.
   The patient presented to Metowest ED with a BP of 194/138
with pulse 110 and 2+ piting edema.  ECG was read as NSR with
LVH and non-specific anterior T and ST abnormalities.  CXR
showed curly B-lines with redistribution consistent with CHF.
BNP was 1690, CK 74, troponin 0.05.  He was given 40mg IV lasix
x1, 1 inch nitro past without change in his BP.  Cardiology on
call recommended IV hydralazine, however this was never given as
they had difficulty obtaining hydralazine from the pharmacy at
the time.  He was subsequently started on nitro gtt and
transferred to [**Hospital1 18**] ED.
   At [**Hospital1 18**], the patient received ASA x1, SL NTG and metoprolol
5mg IV x1.  He was then started back on the nitro gtt and
admitted to the CCU.

MEDICAL HISTORY: None (Has not seen a doctor since the 80s)

MEDICATION ON ADMISSION: As outpatient:
1. ASA 325mg once daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS:
On admision to ED: T: 97.7  HR: 72     BP: 294/131    RR: 20
SaO2: 95% on RA
At time of transfer: T: 97.2  HR: 66   BP: 184/96     RR: 22
SaO2: 96% RA
Gen: middle aged caucasian male lying in bed asleep but easily
arousable to verbal stimuli.  Conversing fluently in full
sentences.  NAD
HEENT: EOMI, anicteric, PERRL 2mm bilaterally
Left fundoscopic exam: optic disc difficult to appreciate, no
obvious nicking of vessels, or flame hemorrhage.
Right fundoscopic exam: difficult to assess due to glare.
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Ext: trace to +1 pitting edema
Neuro: CN II-XII grossly intact

FAMILY HISTORY: Father: 1st MI at 55, CA
Mother: [**Name (NI) 11964**]
Pt is the youngest of 9 children.
Brother: CABG at age 50
Brother: CVA ?age
Brother: gall bladder, pancreatitis

SOCIAL HISTORY: Pt is a retired former desk worker.  He has worked at med
records at [**Hospital1 **], desk clert at motel 6, etc in past.  He
admits to occasional drug use but denies smoking, illicit drug
use. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial flutter,Congestive heart failure, unspecified,Unspecified pleural effusion,Acute posthemorrhagic anemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified disorder of kidney and ureter,Family history of ischemic heart disease'}
