CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 63M with CAD s/p CABG ([**2123**]), severe ischemic cardiomyopathy (EF
20%), s/p BiV/ICD, DM2, HTN, OSA, recently started on coumadin
for L apical thrombus during recent hospitalization at [**Location (un) 620**]
([**Date range (1) 23494**]/09), sent in from vascular clinic to ED with increased
SOB, N/V, and fatigue, dry cough x 2 days. Had dyspnea overnight
more than baseline orthopnea ([**3-5**] pillows at home). Wife notes
likely dietary indiscretion 2 days prior.
.
Patient had recent admission to [**Hospital1 **] [**Location (un) 620**] [**Date range (1) 23494**]/09 for
fatigue, body aches, and dyspnea. Found to have worsening EF by
ECHO, and apical thrombus for which he was started on coumadin.
Discharged on increased dose of [**Date range (1) **] and 5 day course of
levofloxacin for empiric tx of bronchitis/PNA.
.
Today in [**Hospital1 18**] ED, initial vitals were T99.8, HR91, BP174/113,
RR30s, O2 sat 88% -> mid 90s on NRB. Diaphoretic, found to be in
respiratory distress, worried about persistent tachypnea ->
intubated with etomidate/succ/midazolam. Denied chest pain at
this time. CXR consistent with fluid overload. ECG showed V
pacing, unchanged from prior. Given rectal ASA, SL nitro,
started on nitro gtt. Bedside ECHO showed mild left ventricular
hypertrophy with marked ventricular dilation and severe global
hypokinesis. Mild to moderate MR, mild pulm HTN. No obvious LV
clot but cannot be excluded. 1st set enzymes negative, BNP 1095.
Cards consult called, plan for admit to CCU for likely
decompensated heart failure. Planned for [**Hospital1 **], but not given
due to low BP. Foley placed, 100cc urine output on own. Vitals
on transfer were HR60, 97/53, RR20, O2 100%, vent settings CMV,
TV 500, FiO2 80, PEEP 5.
.
On arrival to CCU, patient sedated, but able to respond to
questions appropriately, denied chest pain. Able to recognize
family.
.
Full ROS unable to be obtained as patient intubated with
sedation but denies any chest pain, hemoptysis, changes in bowel
movements. Had 1 day of cough without sputum.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on [**2123-3-4**] (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
15-25%)
-PACING/ICD: BiV pacer for ventricular
arrhythmias
3. OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair ([**2119**]),
Infrarenal AAA of 3 cm s/p repair [**2119**]
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA

MEDICATION ON ADMISSION: - [**Telephone/Fax (1) 11573**] 60-100 mg daily (Discharged on [**5-7**] with 100mg daily x 3
days then 80mg daily)
-Coumadin 5mg, then INR to be checked
-s/p 5 day course of levofloxacin (500 mg daily for 5 days on
[**5-7**] for empiric treatment for bronchitis and pneumonia)
-folic acid 1 mg daily
-Lexapro 20 mg daily,
-lisinopril 10 mg daily
-allopurinol 200 mg b.i.d.
-amiodarone 200 mg daily
-aspirin 81 daily
-carvedilol 25mg b.i.d.
-digoxin 0.125 mcg every other day
-Lipitor 80 mg at bedtime
-Klonopin 0.5 mg t.i.d. p.r.n.
-Flexeril 10 mg p.r.n.
-Protonix 40 mg b.i.d.
-Zantac 300 daily
-Zetia 10 mg at bedtime
-Lantus 70 units subcutaneous b.i.d.
-Humalog sliding scale
-ASA 81mg daily
-Advair daily
-Flomax .4mg daily
-Lexapro 20mg daily

ALLERGIES: Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Hydrochlorothiazide / Aldactone / Inspra

PHYSICAL EXAM: VS: T= 98.9 BP= 114/53 HR= 65 RR= 16 O2 sat= 100% on CMV TV 500,
FiO2 100, PEEP 5
GENERAL: Middle aged man intubated, sedated, able to wake up
with verbal stimulation and answer questions by nodding
appropriately
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
heard
LUNGS: Rhonchorous anteriorly
ABDOMEN: Soft, obese, possible fluid wave, NT. No abdominial
bruits.
EXTREMITIES: 1+ pitting edema to knee, R>L
SKIN: old venous stasis changes bilaterally
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: Father with MI in 50s

SOCIAL HISTORY: He lives with his wife in [**Name (NI) **].
-Tobacco history: Ex-smoker, with 40 pack-year smoking history
-ETOH: None, with no history
-Illicit drugs: None
Acute respiratory failure,Acute on chronic systolic heart failure,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Gout, unspecified,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Coronary atherosclerosis of unspecified type of vessel, native or graft,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin
Acute respiratry failure,Ac on chr syst hrt fail,Chr kidney dis stage III,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Esophageal reflux,Gout NOS,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Elev transaminase/ldh,Cor ath unsp vsl ntv/gft,Obstructive sleep apnea,Aortocoronary bypass,Status autm crd dfbrltr,Long-term use of insulin
Admission Date:  [**2127-5-20**]              Discharge Date:   [**2127-5-23**]

Date of Birth:  [**2064-3-13**]             Sex:   M

Service: MEDICINE

Allergies:
Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Hydrochlorothiazide / Aldactone / Inspra

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
63M with CAD s/p CABG ([**2123**]), severe ischemic cardiomyopathy (EF
20%), s/p BiV/ICD, DM2, HTN, OSA, recently started on coumadin
for L apical thrombus during recent hospitalization at [**Location (un) 620**]
([**Date range (1) 23494**]/09), sent in from vascular clinic to ED with increased
SOB, N/V, and fatigue, dry cough x 2 days. Had dyspnea overnight
more than baseline orthopnea ([**3-5**] pillows at home). Wife notes
likely dietary indiscretion 2 days prior.
.
Patient had recent admission to [**Hospital1 **] [**Location (un) 620**] [**Date range (1) 23494**]/09 for
fatigue, body aches, and dyspnea. Found to have worsening EF by
ECHO, and apical thrombus for which he was started on coumadin.
Discharged on increased dose of [**Date range (1) **] and 5 day course of
levofloxacin for empiric tx of bronchitis/PNA.
.
Today in [**Hospital1 18**] ED, initial vitals were T99.8, HR91, BP174/113,
RR30s, O2 sat 88% -> mid 90s on NRB. Diaphoretic, found to be in
respiratory distress, worried about persistent tachypnea ->
intubated with etomidate/succ/midazolam. Denied chest pain at
this time. CXR consistent with fluid overload. ECG showed V
pacing, unchanged from prior. Given rectal ASA, SL nitro,
started on nitro gtt. Bedside ECHO showed mild left ventricular
hypertrophy with marked ventricular dilation and severe global
hypokinesis. Mild to moderate MR, mild pulm HTN. No obvious LV
clot but cannot be excluded. 1st set enzymes negative, BNP 1095.
Cards consult called, plan for admit to CCU for likely
decompensated heart failure. Planned for [**Hospital1 **], but not given
due to low BP. Foley placed, 100cc urine output on own. Vitals
on transfer were HR60, 97/53, RR20, O2 100%, vent settings CMV,
TV 500, FiO2 80, PEEP 5.
.
On arrival to CCU, patient sedated, but able to respond to
questions appropriately, denied chest pain. Able to recognize
family.
.
Full ROS unable to be obtained as patient intubated with
sedation but denies any chest pain, hemoptysis, changes in bowel
movements. Had 1 day of cough without sputum.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.


Past Medical History:
. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on [**2123-3-4**] (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
15-25%)
-PACING/ICD: BiV pacer for ventricular
arrhythmias
3. OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair ([**2119**]),
Infrarenal AAA of 3 cm s/p repair [**2119**]
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA


Social History:
He lives with his wife in [**Name (NI) **].
-Tobacco history: Ex-smoker, with 40 pack-year smoking history
-ETOH: None, with no history
-Illicit drugs: None

Family History:
Father with MI in 50s

Physical Exam:
VS: T= 98.9 BP= 114/53 HR= 65 RR= 16 O2 sat= 100% on CMV TV 500,
FiO2 100, PEEP 5
GENERAL: Middle aged man intubated, sedated, able to wake up
with verbal stimulation and answer questions by nodding
appropriately
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
heard
LUNGS: Rhonchorous anteriorly
ABDOMEN: Soft, obese, possible fluid wave, NT. No abdominial
bruits.
EXTREMITIES: 1+ pitting edema to knee, R>L
SKIN: old venous stasis changes bilaterally
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:
TTE ([**2127-5-20**]):  The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is severely dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25 %). The left ventricular
apex is heavily trabeculated, and a left ventricular
mass/thrombus cannot be excluded. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. The study is inadequate to
exclude significant aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric jet
of mild to moderate ([**1-3**]+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with marked
ventricular dilation and severe global hypokinesis. Mild to
moderate mitral regurgitation. Mild pulmonary hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2127-5-6**], a left ventricular apical thrombus is
not definitively seen. A supravalvular aortic membrane is not
clearly identified.

EKG ([**2127-5-20**]):  Sinus rhythm with ventricular demand pacing.
Pacemaker rhythm - no further analysis. Since previous tracing
of [**2126-9-20**], the heart rate has increased.

CXR 1V ([**2127-5-20**]):   In comparison with study of [**10-27**], there is
huge enlargement of the cardiac silhouette consistent with
cardiomyopathy. However, there has been substantial increase
engorgement of pulmonary vascularity consistent with the
clinical impression of superimposed congestive failure.
Pacemaker device remains in place.

CXR 1V ([**2127-5-21**]):  Significant interval improvement in pulmonary
edema has been demonstrated which is almost completely resolved.
Left retrocardiac opacities are most likely due to atelectasis
rather than residual pulmonary edema. Cardiomegaly is severe and
unchanged. The position of the biventricular pacemaker leads is
unchanged. There is small most likely bilateral pleural
effusion, decreased since the prior study.

TTE ([**2127-5-22**]):  There is an apical left ventricular aneurysm.
There is severe global left ventricular hypokinesis (LVEF = 20
%). No masses or thrombi are seen in the left ventricle. There
is no pericardial effusion. IMPRESSION: No apical thrombus.

[**2127-5-23**]
WBC-6.9 Hgb-10.9* Hct-34.6* MCV-82 Plt Ct-121*
Neuts-79.5* Lymphs-13.4* Monos-4.4 Eos-2.3 Baso-0.4
PT-22.5* PTT-35.5* INR(PT)-2.2*
Glucose-78 UreaN-39* Creat-2.2* Na-145 K-3.3 Cl-102 HCO3-33*
ALT-41* AST-40 LD(LDH)-278* CK(CPK)-138 AlkPhos-126* TotBili-0.9
Lipase-79*

cTropnT-0.01 > 0.04* > 0.04*
proBNP-1095*
Digoxin-1.0
CK(CPK)-138 > 105 > 102

Brief Hospital Course:
63 year-old male with coronary artery disease, dilated
cardiomyopathy (EF 20%) status-post BiV/ICD, diabetes mellitus
type II, hypertension, obstructive sleep apnea, recently started
on coumadin for left apical thrombus admitted with respiratory
distress secondary to decompensated heart failure. Hospital
course was as follows.

1. Respiratory failure:  Patient was intubated in emergency
department for tachypnea, hypoxia. Decompensated heart failure
was most likely underlying etiology given exam consistent with
fluid overload, fluid congestion on chest radiograph, elevated
BNP, and recent history of dietary noncompliance. Patient was
diuresed and extubated within hours of admission to CCU.

2. Decompensated systolic heart failure:  Patient with known
hypertensive cardiomyopathy followed by Dr. [**First Name (STitle) 437**] in heart
failure service. s/p BiV/ICD interrogated in [**3-10**] with no
problems. EF 15-20% from recent ECHO in [**Location (un) 620**]. Exam consistent
with volume overload including JVD, crackles, and lower
extremity edema. Effusions were seen on chest radiograph. Recent
diet and fluid restriction noncompliance as inciting factor for
decompensated heart failure. As above, patient was intubated in
ED for hypoxia. Nitro gtt was started, and rapidly weaned off in
CCU. Patient was diuresed successfully with [**Location (un) 11573**] 100mg IV, then
downtitrated to [**Location (un) 11573**] 60mg IV and finally [**Location (un) 11573**] 100mg PO qAM and
60mg PO qPM. He was continued on digoxin, lisinopril,
beta-blocker. He was given a low-salt diet and fluid restricted,
and was counseled on the importance of sodium and fluid
restriction.

3. CORONARIES:  Known CAD s/p CABG. No chest pain or indications
of ACS. Troponin was elevated but CK flat. ECG paced and without
evidence of ischemia. He was continued on ASA, beta-blocker, ACE
inhibitor, and statin.

4. RHYTHM:  Atrial and ventricular paced (underlying rhythm is
sinus brady). On amiodarone for afib in past. Patient was
continued on amiodarone. He reported having been on coumadin
several years ago particularly for atrial fibrillation but had
been stopped for an unknown reason. As below, he recently had
been restarted on coumadin for a separate reason.

5. Recent possible left apical clot:  Noted on TTE at [**Hospital1 **]
[**Location (un) 620**]. Repeat TTE with Definity showed no evidence of a clot.
Coumadin was thus held.

6. Diabetes mellitus, type II:  Continued home Lantus and
Humalog sliding scale.

7. Chronic kidney disease:  Stable from discharge on [**2127-5-9**].
Likely related to diabetes, hypertension.

8. Dyslipidemia:  Continued Lipitor per home regimen.

9. Depression:  Continued escitalopram per home regimen.

**Communication:  [**Name (NI) **] (wife), ([**Telephone/Fax (1) 100532**]

Medications on Admission:
- [**Telephone/Fax (1) 11573**] 60-100 mg daily (Discharged on [**5-7**] with 100mg daily x 3
days then 80mg daily)
-Coumadin 5mg, then INR to be checked
-s/p 5 day course of levofloxacin (500 mg daily for 5 days on
[**5-7**] for empiric treatment for bronchitis and pneumonia)
-folic acid 1 mg daily
-Lexapro 20 mg daily,
-lisinopril 10 mg daily
-allopurinol 200 mg b.i.d.
-amiodarone 200 mg daily
-aspirin 81 daily
-carvedilol 25mg b.i.d.
-digoxin 0.125 mcg every other day
-Lipitor 80 mg at bedtime
-Klonopin 0.5 mg t.i.d. p.r.n.
-Flexeril 10 mg p.r.n.
-Protonix 40 mg b.i.d.
-Zantac 300 daily
-Zetia 10 mg at bedtime
-Lantus 70 units subcutaneous b.i.d.
-Humalog sliding scale
-ASA 81mg daily
-Advair daily
-Flomax .4mg daily
-Lexapro 20mg daily

Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.

4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
12. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
14. Lantus 100 unit/mL Solution Sig: Seventy (70) units
Subcutaneous twice a day.
15. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
17. Humalog Mix 75-25 100 unit/mL (75-25) Suspension Sig: as per
sliding scale units Subcutaneous three times a day: before
meals.
18. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day:
early in the morning.
Disp:*150 Tablet(s)* Refills:*2*
21. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
at 1-2pm.
22. Omega-3 Fish Oil 1,000-5 mg-unit Capsule Sig: One (1)
Capsule PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Acute on chronic Systolic Congestive Heart Failure
Diabetes Mellitus Type 2
Transaminitis
Hypertension


Discharge Condition:
Hemodynamically stable. Maintaining O2 saturation with
ambulation, on room air. Continues to diurese well.

Discharge Instructions:
You had an episode of congestive heart failure where fluid
filled up your lungs causing you to be intubated. We
aggressively diuresed you with intravenous [**Month/Day (4) **] and
transitioned you to oral [**Month/Day (4) **] before discharge. Your current
weight is 233 pounds. You goal weight is likely around 220-225
pounds or when you are able to lie almost flat to sleep and you
have no swelling in your legs. It is very important to follow
your low sodium diet and limit your fluid intake to 1500cc per
day or about 6 cups of fluid. Please also be sure to count the
fluid from a popsicle in the daily total. Please take your first
dose of [**Month/Day (4) 11573**] early in the morning and the second dose about
1-2pm. If you limit your fluids, you should not be up at night
to urinate.
.
Medicine changes:
1. Warfarin (coumadin): you do NOT have to continue this as the
Echocardiogram did not show a clot.
2. Furosemide: 100mg in the morning, 60 mg at night
3. Please talk to Dr. [**Last Name (STitle) 1407**] about whether to continue your
inhalers
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc or 3 Poland spring [**1-3**] liter bottles

Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) 20**] R. Phone: [**Telephone/Fax (1) 1408**] Date/Time: Tuesday [**5-27**]
at 3:30pm.
Cardiology Heart Failure:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2127-6-2**] 1:00

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Completed by:[**2127-5-28**]
{'Acute respiratory failure,Acute on chronic systolic heart failure,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Gout, unspecified,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Coronary atherosclerosis of unspecified type of vessel, native or graft,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin'}


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: Respiratory distress

PRESENT ILLNESS: 63M with CAD s/p CABG ([**2123**]), severe ischemic cardiomyopathy (EF
20%), s/p BiV/ICD, DM2, HTN, OSA, recently started on coumadin
for L apical thrombus during recent hospitalization at [**Location (un) 620**]
([**Date range (1) 23494**]/09), sent in from vascular clinic to ED with increased
SOB, N/V, and fatigue, dry cough x 2 days. Had dyspnea overnight
more than baseline orthopnea ([**3-5**] pillows at home). Wife notes
likely dietary indiscretion 2 days prior.
.
Patient had recent admission to [**Hospital1 **] [**Location (un) 620**] [**Date range (1) 23494**]/09 for
fatigue, body aches, and dyspnea. Found to have worsening EF by
ECHO, and apical thrombus for which he was started on coumadin.
Discharged on increased dose of [**Date range (1) **] and 5 day course of
levofloxacin for empiric tx of bronchitis/PNA.
.
Today in [**Hospital1 18**] ED, initial vitals were T99.8, HR91, BP174/113,
RR30s, O2 sat 88% -> mid 90s on NRB. Diaphoretic, found to be in
respiratory distress, worried about persistent tachypnea ->
intubated with etomidate/succ/midazolam. Denied chest pain at
this time. CXR consistent with fluid overload. ECG showed V
pacing, unchanged from prior. Given rectal ASA, SL nitro,
started on nitro gtt. Bedside ECHO showed mild left ventricular
hypertrophy with marked ventricular dilation and severe global
hypokinesis. Mild to moderate MR, mild pulm HTN. No obvious LV
clot but cannot be excluded. 1st set enzymes negative, BNP 1095.
Cards consult called, plan for admit to CCU for likely
decompensated heart failure. Planned for [**Hospital1 **], but not given
due to low BP. Foley placed, 100cc urine output on own. Vitals
on transfer were HR60, 97/53, RR20, O2 100%, vent settings CMV,
TV 500, FiO2 80, PEEP 5.
.
On arrival to CCU, patient sedated, but able to respond to
questions appropriately, denied chest pain. Able to recognize
family.
.
Full ROS unable to be obtained as patient intubated with
sedation but denies any chest pain, hemoptysis, changes in bowel
movements. Had 1 day of cough without sputum.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: CAD, s/p CABG (4 vessel CABG on [**2123-3-4**] (LIMA
to LAD, SVG to OM, ramus, RCA); Ischemic cardiomyopathy (EF
15-25%)
-PACING/ICD: BiV pacer for ventricular
arrhythmias
3. OTHER PAST MEDICAL HISTORY:
1. HTN
2. Prostatitis
3. Melanoma s/p excisions
4. DM2
5. Afib in past, prior to BiV pacer
6. GERD
7. gout
8. Sleep apnea
9. s/p hemorrhoidectomy
10. bilateral Iliac artery aneurysm s/p repair ([**2119**]),
Infrarenal AAA of 3 cm s/p repair [**2119**]
11. Hypertensive cardiomyopathy
12. Hypercholesterolemia
13. Cervical radiculopathy
14. Recurrent PNA

MEDICATION ON ADMISSION: - [**Telephone/Fax (1) 11573**] 60-100 mg daily (Discharged on [**5-7**] with 100mg daily x 3
days then 80mg daily)
-Coumadin 5mg, then INR to be checked
-s/p 5 day course of levofloxacin (500 mg daily for 5 days on
[**5-7**] for empiric treatment for bronchitis and pneumonia)
-folic acid 1 mg daily
-Lexapro 20 mg daily,
-lisinopril 10 mg daily
-allopurinol 200 mg b.i.d.
-amiodarone 200 mg daily
-aspirin 81 daily
-carvedilol 25mg b.i.d.
-digoxin 0.125 mcg every other day
-Lipitor 80 mg at bedtime
-Klonopin 0.5 mg t.i.d. p.r.n.
-Flexeril 10 mg p.r.n.
-Protonix 40 mg b.i.d.
-Zantac 300 daily
-Zetia 10 mg at bedtime
-Lantus 70 units subcutaneous b.i.d.
-Humalog sliding scale
-ASA 81mg daily
-Advair daily
-Flomax .4mg daily
-Lexapro 20mg daily

ALLERGIES: Hydrochlorothiazide / Demerol / Ambien / Strawberry / Wheat Bran
/ Hydrochlorothiazide / Aldactone / Inspra

PHYSICAL EXAM: VS: T= 98.9 BP= 114/53 HR= 65 RR= 16 O2 sat= 100% on CMV TV 500,
FiO2 100, PEEP 5
GENERAL: Middle aged man intubated, sedated, able to wake up
with verbal stimulation and answer questions by nodding
appropriately
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
heard
LUNGS: Rhonchorous anteriorly
ABDOMEN: Soft, obese, possible fluid wave, NT. No abdominial
bruits.
EXTREMITIES: 1+ pitting edema to knee, R>L
SKIN: old venous stasis changes bilaterally
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: Father with MI in 50s

SOCIAL HISTORY: He lives with his wife in [**Name (NI) **].
-Tobacco history: Ex-smoker, with 40 pack-year smoking history
-ETOH: None, with no history
-Illicit drugs: None 

### Response:
{'Acute respiratory failure,Acute on chronic systolic heart failure,Chronic kidney disease, Stage III (moderate),Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Esophageal reflux,Gout, unspecified,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Coronary atherosclerosis of unspecified type of vessel, native or graft,Obstructive sleep apnea (adult)(pediatric),Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin'}
