CHIEF COMPLAINT: s/p Cardiac Arrest

PRESENT ILLNESS: 65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. He originally presented to hospital as outpatient
for planned [**Year (4 digits) **], which was cancelled due to tachycardia,
relative hypotension, and inability to find oxygen sat. Patient
then left the hospital to go home and had a witnessed Vfib
arrest with intubation in field and epi down ETT. Was shocked
out of Vfib. FS at that time was 132.
.
*per phone conversation with patient's wife*
In last few weeks patient had been complaining to his wife that
he was more short of breath with exertion. Wife reports that
patient acted like he had given up on life as he had no
motivation to do even the smallest thing like change his
underwear. She notes that he was sleeping through most of the
day. Patient also may have been a bit more confusion lately.
Patient finished 6.5 weeks of radiation therapy last week.
Patient has also finished multiple cycles of gemcitabine
chemotherapy. Of note, wife is very angry about the fact that
patient was released to home from GI procedure suite today. She
resports that she feels it was inappropriate to send a
"half-dead" man home.
.
In the emergency department, vitals at presentation were: T
96.6, HR 112, BP 125/32, and intubated with O2Sat 100%. Patient
had multiple impaging procedures including negative CT head, CT
abd/pelvis showing large simple ascites, CTA chest without PE
but did show multiple right rib fractures and sternal fracture.
Currently being cooled (target reached at 33 C) and on a
midazolam drip. EKG without concern for STEMI, and cardiology
feels this is close to his baseline EKG. Prior to transfer to
the ICU vitals were: T 92 98, HR , BP 101/58, RR 25, O2Sat 100%
on AC mode Vt 560, f 22, PEEP 5, FiO2 100%.

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: per [**2159-9-4**] [**Hospital6 33**] discharge*
1) Atorvastatin 40 mg QHS
2) Lipase-Protease-Amylase 5,000-17,000-27,000 Capsule, TID
W/MEALS
3) Metoprolol Tartrate 25 mg PO DAILY
4) Trazodone 50 mg PO HS
5) Insulin Glargine 8 Units subcutaneous DAILY
6) Humalog 100 unit/mL 1-12 Units subcutaneous QID
7) Aspirin 81 mg PO DAILY
8) Pantoprazole 20 mg Q24H
9) Furosemide 40 mg Tablet PO DAILY
10) Digoxin 0.125 mg DAILY
11) Tamsulosin 0.4 mg DAILY
12) Ferrous gluconate DAILY

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T 33 C, HR 99, BP 100/59, RR 22, O2Sat 100%
VENT: AC with Vt 560, f 22, PEEP 5, FiO2 100%
GEN: Intubated and sedated, appears cachectic
HEENT: Scleral edema, PERRL 3->2 mm
NECK: EJ IV catheter at right neck
PULM: Anterior chest bruising
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Largely obscured by placement of Artic Sun pads, though
BS+, soft, no grimace with palpation
EXT: Stage III ulcer on right heel, BLE with woody edema, BUE
[**11-25**]+ pitting edema
NEURO: Sedated, no rigidity of muscular tone
.

FAMILY HISTORY: Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.

SOCIAL HISTORY: Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use.
Acute on chronic systolic heart failure,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Malignant neoplasm of pancreas, part unspecified,Ventricular fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Long-term (current) use of insulin,Cardiogenic shock,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified
Ac on chr syst hrt fail,Acute respiratry failure,Ac kidny fail, tubr necr,Anoxic brain damage,Malig neo pancreas NOS,Ventricular fibrillation,DMII wo cmp nt st uncntr,Crnry athrscl natve vssl,Long-term use of insulin,Cardiogenic shock,BPH w/o urinary obs/LUTS,Chronic kidney dis NOS
Admission Date:  [**2159-9-27**]              Discharge Date:   [**2159-9-30**]

Date of Birth:  [**2094-9-7**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
s/p Cardiac Arrest

Major Surgical or Invasive Procedure:
Arterial line placement
Intubation

History of Present Illness:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. He originally presented to hospital as outpatient
for planned [**Year (4 digits) **], which was cancelled due to tachycardia,
relative hypotension, and inability to find oxygen sat. Patient
then left the hospital to go home and had a witnessed Vfib
arrest with intubation in field and epi down ETT. Was shocked
out of Vfib. FS at that time was 132.
.
*per phone conversation with patient's wife*
In last few weeks patient had been complaining to his wife that
he was more short of breath with exertion. Wife reports that
patient acted like he had given up on life as he had no
motivation to do even the smallest thing like change his
underwear. She notes that he was sleeping through most of the
day. Patient also may have been a bit more confusion lately.
Patient finished 6.5 weeks of radiation therapy last week.
Patient has also finished multiple cycles of gemcitabine
chemotherapy. Of note, wife is very angry about the fact that
patient was released to home from GI procedure suite today. She
resports that she feels it was inappropriate to send a
"half-dead" man home.
.
In the emergency department, vitals at presentation were: T
96.6, HR 112, BP 125/32, and intubated with O2Sat 100%. Patient
had multiple impaging procedures including negative CT head, CT
abd/pelvis showing large simple ascites, CTA chest without PE
but did show multiple right rib fractures and sternal fracture.
Currently being cooled (target reached at 33 C) and on a
midazolam drip. EKG without concern for STEMI, and cardiology
feels this is close to his baseline EKG. Prior to transfer to
the ICU vitals were: T 92 98, HR , BP 101/58, RR 25, O2Sat 100%
on AC mode Vt 560, f 22, PEEP 5, FiO2 100%.

Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

Social History:
Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use.


Family History:
Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.


Physical Exam:
VS: T 33 C, HR 99, BP 100/59, RR 22, O2Sat 100%
VENT: AC with Vt 560, f 22, PEEP 5, FiO2 100%
GEN: Intubated and sedated, appears cachectic
HEENT: Scleral edema, PERRL 3->2 mm
NECK: EJ IV catheter at right neck
PULM: Anterior chest bruising
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Largely obscured by placement of Artic Sun pads, though
BS+, soft, no grimace with palpation
EXT: Stage III ulcer on right heel, BLE with woody edema, BUE
[**11-25**]+ pitting edema
NEURO: Sedated, no rigidity of muscular tone
.


Pertinent Results:
Admission Labs
[**2159-9-27**] 11:17PM   TYPE-ART TEMP-33 RATES-22/ TIDAL VOL-609
PEEP-5 O2-50 PO2-255* PCO2-22* PH-7.38 TOTAL CO2-14* BASE XS--9
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 11:17PM   LACTATE-2.5*
[**2159-9-27**] 09:19PM   TYPE-[**Last Name (un) **] PH-7.23* COMMENTS-GREEN TOP
[**2159-9-27**] 09:19PM   LACTATE-2.6*
[**2159-9-27**] 09:19PM   freeCa-1.04*
[**2159-9-27**] 09:07PM   GLUCOSE-112* UREA N-33* CREAT-1.6* SODIUM-144
POTASSIUM-5.8* CHLORIDE-118* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 09:07PM   CK(CPK)-352*
[**2159-9-27**] 09:07PM   CK-MB-55* MB INDX-15.6* cTropnT-0.73*
[**2159-9-27**] 09:07PM   DIGOXIN-0.2*
[**2159-9-27**] 09:07PM   WBC-9.8 RBC-3.10* HGB-9.6* HCT-30.4* MCV-98
MCH-30.8 MCHC-31.5 RDW-21.7*
[**2159-9-27**] 09:07PM   PLT COUNT-191
[**2159-9-27**] 09:07PM   PT-16.9* PTT-33.6 INR(PT)-1.5*
[**2159-9-27**] 08:10PM   GLUCOSE-107* UREA N-34* CREAT-1.6* SODIUM-140
POTASSIUM-8.6* CHLORIDE-117* TOTAL CO2-16* ANION GAP-16
[**2159-9-27**] 08:10PM   CK(CPK)-412*
[**2159-9-27**] 08:10PM   CK-MB-53* MB INDX-12.9* cTropnT-0.63*
[**2159-9-27**] 08:10PM   CALCIUM-7.7* PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2159-9-27**] 03:21PM   TYPE-ART TIDAL VOL-520 O2-100 PO2-329*
PCO2-30* PH-7.30* TOTAL CO2-15* BASE XS--9 AADO2-362 REQ O2-64
-ASSIST/CON INTUBATED-INTUBATED
[**2159-9-27**] 01:55PM URINE  HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE  HOURS-RANDOM
[**2159-9-27**] 01:55PM URINE  GR HOLD-HOLD
[**2159-9-27**] 01:55PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2159-9-27**] 01:55PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2159-9-27**] 01:55PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-9-27**] 01:38PM   GLUCOSE-119* LACTATE-4.0* NA+-143 K+-5.7*
CL--118* TCO2-15*
[**2159-9-27**] 01:30PM   UREA N-33* CREAT-1.7*
[**2159-9-27**] 01:30PM   estGFR-Using this
[**2159-9-27**] 01:30PM   estGFR-Using this
[**2159-9-27**] 11:59AM   TYPE-ART PO2-294* PCO2-28* PH-7.39 TOTAL
CO2-18* BASE XS--6 INTUBATED-NOT INTUBA
[**2159-9-27**] 01:30PM   FIBRINOGE-220
[**2159-9-27**] 01:30PM   PLT COUNT-239
[**2159-9-27**] 01:30PM   PT-16.4* PTT-33.4 INR(PT)-1.5*
[**2159-9-27**] 01:30PM   WBC-6.7 RBC-3.38* HGB-10.4* HCT-33.3* MCV-99*
MCH-30.8 MCHC-31.3 RDW-21.8*
[**2159-9-27**] 01:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
Discharge Labs

[**2159-9-30**] 05:43AM BLOOD WBC-10.6 RBC-2.76* Hgb-8.6* Hct-26.8*
MCV-97 MCH-31.1 MCHC-32.0 RDW-21.8* Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD WBC-8.8 RBC-2.98* Hgb-9.3* Hct-29.2*
MCV-98 MCH-31.0 MCHC-31.7 RDW-21.8* Plt Ct-169
[**2159-9-28**] 04:46AM BLOOD WBC-9.4 RBC-3.20* Hgb-10.0* Hct-30.8*
MCV-96 MCH-31.3 MCHC-32.5 RDW-21.5* Plt Ct-177
[**2159-9-28**] 04:46AM BLOOD Neuts-95.6* Lymphs-1.8* Monos-2.4 Eos-0.1
Baso-0
[**2159-9-30**] 05:43AM BLOOD Plt Ct-134*
[**2159-9-29**] 01:52AM BLOOD Plt Ct-169
[**2159-9-28**] 12:54PM BLOOD PT-17.0* PTT-113.2* INR(PT)-1.5*
[**2159-9-28**] 04:46AM BLOOD Plt Ct-177
[**2159-9-30**] 05:43AM BLOOD Glucose-120* UreaN-39* Creat-2.1* Na-139
K-4.9 Cl-113* HCO3-18* AnGap-13
[**2159-9-29**] 07:49PM BLOOD Glucose-120* UreaN-39* Creat-2.0* Na-138
K-5.0 Cl-113* HCO3-18* AnGap-12
[**2159-9-29**] 04:04PM BLOOD Glucose-124* UreaN-39* Creat-1.9* Na-140
K-5.0 Cl-114* HCO3-19* AnGap-12
[**2159-9-29**] 01:52AM BLOOD Glucose-256* UreaN-37* Creat-1.7* Na-142
K-5.2* Cl-113* HCO3-16* AnGap-18
[**2159-9-28**] 04:46AM BLOOD ALT-31 AST-64* LD(LDH)-370* CK(CPK)-372*
AlkPhos-132* TotBili-1.0
[**2159-9-27**] 09:07PM BLOOD CK(CPK)-352*
[**2159-9-28**] 04:46AM BLOOD CK-MB-62* MB Indx-16.7* cTropnT-0.67*
[**2159-9-27**] 09:07PM BLOOD CK-MB-55* MB Indx-15.6* cTropnT-0.73*
[**2159-9-27**] 08:10PM BLOOD CK-MB-53* MB Indx-12.9* cTropnT-0.63*
[**2159-9-30**] 05:43AM BLOOD Calcium-7.8* Phos-4.5 Mg-1.9
[**2159-9-29**] 07:49PM BLOOD Calcium-7.7* Phos-4.5 Mg-2.0
[**2159-9-29**] 04:04PM BLOOD Calcium-7.6* Phos-4.1 Mg-2.0
[**2159-9-29**] 01:52AM BLOOD Calcium-7.9* Phos-4.2 Mg-2.1
[**2159-9-30**] 05:43AM BLOOD Phenyto-9.0*
[**2159-9-29**] 07:49PM BLOOD Phenyto-8.8*
[**2159-9-27**] 09:07PM BLOOD Digoxin-0.2*
[**2159-9-27**] 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-9-29**] 08:32AM BLOOD Type-ART Temp-36.1 Rates-12/14 PEEP-5
FiO2-30 pO2-110* pCO2-35 pH-7.34* calTCO2-20* Base XS--5
-ASSIST/CON Intubat-INTUBATED
[**2159-9-29**] 03:37AM BLOOD Type-ART Temp-35.0 Rates-[**10-25**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.3 pO2-92 pCO2-34 pH-7.33* calTCO2-19*
Base XS--6 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 01:57AM BLOOD Type-ART Temp-34.3 Rates-[**10-26**] Tidal V-450
PEEP-5 FiO2-30 pO2-89 pCO2-31* pH-7.33* calTCO2-17* Base XS--8
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 11:44PM BLOOD Type-ART Temp-33.6 Rates-[**10-29**] Tidal V-450
PEEP-5 FiO2-30 pO2-93 pCO2-28* pH-7.31* calTCO2-15* Base XS--10
Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-28**] 10:36PM BLOOD Type-ART Temp-33.3 Rates-[**10-27**] Tidal V-450
PEEP-5 FiO2-30 O2 Flow-6.2 pO2-132* pCO2-32* pH-7.27*
calTCO2-15* Base XS--10 Intubat-INTUBATED Vent-CONTROLLED
[**2159-9-29**] 04:42PM BLOOD Lactate-1.8 Cl-114*
.
Reports
[**2159-9-27**]
Regular rhythm at 97 beats per minute. In leads V5-V6 there are
P waves so
this is probably sinus rhythm at 97 beats per minute. Marked low
voltage in the limb leads persists. The right bundle-branch
block pattern persists with a QRS duration which has widened to
158 milliseconds. There is poor R wave progression laterally and
low voltage in all leads. There are small Q waves in leads II,
III and aVF with ST segment elevation in those leads. Consider
acute inferior myocardial infarction.
.
[**9-27**] CT head w/o Contrast
IMPRESSION: No acute intracranial process.
.
[**2159-9-27**] Chest CT w contrast
. No central PE or dissection. Suboptimal evaluation of the
posterior
pulmonary circulation secondary to large bilateral pleural
effusions with
associated compressive atelectasis.
2. Focal small foci of gas in the anterior upper abdomen on the
last image of
non-contrast sequence. Free air cannot be excluded.
3. Large amount of abdominal ascites.
4. Multiple right and left rib fractures and a sternal fracture.
These may be
related to recent resuscitative efforts.
5. Ground-glass opacity in the right middle lobe may be a
pulmonary contusion
versus infection versus aspiration. This is new since [**2159-7-19**].

.
CT abdomen
Large volume ascites with no evidence of free air..
.
ECHO
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with near
akinesis of the inferior and inferolateral walls and hypokinesis
of the remaining segments. The anterior septum contracts best
(LVEF 25-30%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The estimated cardiac index is depressed
(<2.0L/min/m2). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is dilated with moderate global free wall
hypokinesis. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The aortic root is mildly dilated at the sinus
level. 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. Severe
(4+) mitral regurgitation is seen. Moderate to severe [3+]
tricuspid regurgitation is seen. There is severe pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2159-4-25**], the
estimated pulmonary artery systolic pressure is now highter.
.
[**9-29**] CXR
Cardiomegaly, large bilateral pleural effusions greater on the
right side with
associated atelectases are unchanged. ET tube, NG tube, and
right central
catheter remain in place. There is no pneumothorax.
Cardiomediastinal
silhouette is unchanged.


Brief Hospital Course:
65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. Is being cooled with Artic Sun.



#. Vfib cardiac arrest:
Most likely etiology was either new ischemia or automaticity
from old scar in setting of dilated ischemic cardiomyopathy with
LVEF of 25-30%. Patient's exam and history was consistent with
decompensated heart failure of at least several week duration.
Less likely cause of cardiac arrest would be digoxin toxicity
given patient recently started that medication and has history
of renal insufficiency. CTA chest was overall a poor study given
large pleural effusions, though no apparent PE or aortic
dissection. Patient fortunately had relatively rapid
defibrillation and [**Name (NI) **] during code. He was being cooled
followed by warmed on Artic Sun for neuro protection and has
reached temperature goal of 33 C.  48hr EEG showed possible
seizure activity consistent with ischemic injury; consult neuro
to evaluate EEG
Family meeting once warmed and off sedation to discuss goals of
care and prognosis, and it was decided to enact comfort care
measures.
.
#Hypotension: likely secondary to worsening heart failure in the
setting of fluid overload. N.epi and vasopressin as needed for
MAP > 60; phenylephrine PRN for additional pressure support
.
#. Acute on Chronic Kidney Injury:Most likely due to ATN in
setting of arrest



Mr [**Known lastname 4017**] wife and son decided they wanted to fully withdraw
care. Dr [**First Name (STitle) 1022**] met with them and answered all questions - pt was
extubated and all pressors were  turned off. Placed on Morphine
for comfort. At approx. 12:45PM, I was notified by the nurse the
patient had passed away with his family at bedside.

.
[**2159-9-30**]
I examined the patient and he was not responsive to auditory or
tactile stimuli. I observed 1 minute of no breaths or
respiratory effort. I auscultated no breath sounds or heart
sounds for 1 minute. The patient did not have a corneal reflex
or pupilllary reaction to direct light bilaterally. I declared
the patient dead at 12:57 PM and notified his family who were in
the hallway outside the ICU.  His wife and son denied a autopsy.






Medications on Admission:
per [**2159-9-4**] [**Hospital6 33**] discharge*
1) Atorvastatin 40 mg QHS
2) Lipase-Protease-Amylase 5,000-17,000-27,000 Capsule, TID
W/MEALS
3) Metoprolol Tartrate 25 mg PO DAILY
4) Trazodone 50 mg PO HS
5) Insulin Glargine 8 Units subcutaneous DAILY
6) Humalog 100 unit/mL 1-12 Units subcutaneous QID
7) Aspirin 81 mg PO DAILY
8) Pantoprazole 20 mg Q24H
9) Furosemide 40 mg Tablet PO DAILY
10) Digoxin 0.125 mg DAILY
11) Tamsulosin 0.4 mg DAILY
12) Ferrous gluconate DAILY


Discharge Medications:
Patient has passed away

Discharge Disposition:
Expired

Discharge Diagnosis:
Patient has passed away

Discharge Condition:
Patient has passed away

Discharge Instructions:
Patient has passed away

Followup Instructions:
Patient has passed away
{'Acute on chronic systolic heart failure,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Malignant neoplasm of pancreas, part unspecified,Ventricular fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Long-term (current) use of insulin,Cardiogenic shock,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified'}


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: 65 yo M with history of pancreatic CA s/p Whipple [**1-/2159**], Afib,
CHF with LVEF 25-30%, and Type II DM who present s/p cardiac
arrest today. He originally presented to hospital as outpatient
for planned [**Year (4 digits) **], which was cancelled due to tachycardia,
relative hypotension, and inability to find oxygen sat. Patient
then left the hospital to go home and had a witnessed Vfib
arrest with intubation in field and epi down ETT. Was shocked
out of Vfib. FS at that time was 132.
.
*per phone conversation with patient's wife*
In last few weeks patient had been complaining to his wife that
he was more short of breath with exertion. Wife reports that
patient acted like he had given up on life as he had no
motivation to do even the smallest thing like change his
underwear. She notes that he was sleeping through most of the
day. Patient also may have been a bit more confusion lately.
Patient finished 6.5 weeks of radiation therapy last week.
Patient has also finished multiple cycles of gemcitabine
chemotherapy. Of note, wife is very angry about the fact that
patient was released to home from GI procedure suite today. She
resports that she feels it was inappropriate to send a
"half-dead" man home.
.
In the emergency department, vitals at presentation were: T
96.6, HR 112, BP 125/32, and intubated with O2Sat 100%. Patient
had multiple impaging procedures including negative CT head, CT
abd/pelvis showing large simple ascites, CTA chest without PE
but did show multiple right rib fractures and sternal fracture.
Currently being cooled (target reached at 33 C) and on a
midazolam drip. EKG without concern for STEMI, and cardiology
feels this is close to his baseline EKG. Prior to transfer to
the ICU vitals were: T 92 98, HR , BP 101/58, RR 25, O2Sat 100%
on AC mode Vt 560, f 22, PEEP 5, FiO2 100%.

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: per [**2159-9-4**] [**Hospital6 33**] discharge*
1) Atorvastatin 40 mg QHS
2) Lipase-Protease-Amylase 5,000-17,000-27,000 Capsule, TID
W/MEALS
3) Metoprolol Tartrate 25 mg PO DAILY
4) Trazodone 50 mg PO HS
5) Insulin Glargine 8 Units subcutaneous DAILY
6) Humalog 100 unit/mL 1-12 Units subcutaneous QID
7) Aspirin 81 mg PO DAILY
8) Pantoprazole 20 mg Q24H
9) Furosemide 40 mg Tablet PO DAILY
10) Digoxin 0.125 mg DAILY
11) Tamsulosin 0.4 mg DAILY
12) Ferrous gluconate DAILY

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: T 33 C, HR 99, BP 100/59, RR 22, O2Sat 100%
VENT: AC with Vt 560, f 22, PEEP 5, FiO2 100%
GEN: Intubated and sedated, appears cachectic
HEENT: Scleral edema, PERRL 3->2 mm
NECK: EJ IV catheter at right neck
PULM: Anterior chest bruising
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Largely obscured by placement of Artic Sun pads, though
BS+, soft, no grimace with palpation
EXT: Stage III ulcer on right heel, BLE with woody edema, BUE
[**11-25**]+ pitting edema
NEURO: Sedated, no rigidity of muscular tone
.

FAMILY HISTORY: Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.

SOCIAL HISTORY: Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use. 

### Response:
{'Acute on chronic systolic heart failure,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Malignant neoplasm of pancreas, part unspecified,Ventricular fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Long-term (current) use of insulin,Cardiogenic shock,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Chronic kidney disease, unspecified'}
