CHIEF COMPLAINT: Epigastric pain and shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 y.o male with a history of nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD who
presented to [**Hospital6 **] with epigastric chest
pain and shortness of breath. At [**Hospital1 487**], he was found to have
a left bundle branch block that was not known to be old and as
such was taken to the cath lab. The LBBB was later noted to be
old, however during cath he was noted to have a total occlusion
to the OM2 as well as 2 tight lesions in the RCA. Of note, the
patient had been found to have inferior septal ischemia on a
stress test during outpatient workup.
In the cath lab, the patient subsequently developed acute
shortness of breath, at which point he was given 100mg of lasix
and started on a nitroglycerin drip. His symptoms did not
improve, at which point he was intubated and an intra-aortic
balloon pump was placed through right femoral access. He also
received angiomax and 300mg of clopidogrel. A swan was placed
which showed elevated pulmonary artery pressures and wedge
pressures between 37-44. Laboratory exam at [**Hospital1 487**] was
significant for Na 129, K 4.1, BUN 53, Cr 1.3, hemoglobin 16.6
and platelets of 135. Her PT was 19.4 and INR was 1.8. Dig level
of 0.8, and cardiac enzymes significant for CK of 135, MB of 7
and Troponin of 0.08 which was negative in their reference
range.
.
Review of systems could not be obtained due to intubation.

MEDICAL HISTORY: CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.

MEDICATION ON ADMISSION: Home medications
Aspirin 81mg daily
lipitor 40mg daily
lisinopril 40mg qd
lopressor 150mg [**Hospital1 **]
digoxin 0.375mg MWF, 0.25mg TTSS
furosemide 160mg [**Hospital1 **]
metolazone 2.5 qweek
Gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lantus 48 units qd
multivitamin
coumadin 5mg TWFSS, 7.5mg MT

ALLERGIES: Penicillins / Actos / Percocet / Cephalosporins

PHYSICAL EXAM: PHYSICAL EXAMINATION on Admission:
VS: T=97.5 BP= 87/38 HR=89 RR=16 O2 sat=100% on 500/18/5/40
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CARDIAC: Fast, irregular, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diffusely rhonchorous with crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema. Right femoral sheath
introducer sheeth and swan in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial, DP 2+ bilaterally.
.

FAMILY HISTORY: Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz

SOCIAL HISTORY: -Tobacco history: Former smoker
-ETOH: no etoh
Is not married.
Acute on chronic systolic heart failure,Unspecified septicemia,Septic shock,Severe sepsis,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Ventilator associated pneumonia,Other primary cardiomyopathies,Candidiasis of mouth,Chronic total occlusion of coronary artery,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified hereditary and idiopathic peripheral neuropathy,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Nontoxic multinodular goiter,Other left bundle branch block,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pure hypercholesterolemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use
Ac on chr syst hrt fail,Septicemia NOS,Septic shock,Severe sepsis,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Acute respiratry failure,Parox ventric tachycard,Hyperosmolality,Ventltr assoc pneumonia,Prim cardiomyopathy NEC,Thrush,Chr tot occlus cor artry,Bacteremia,React-oth vasc dev/graft,Idio periph neurpthy NOS,Other staphylococcus,Nontox multinodul goiter,Left bb block NEC,DMII wo cmp nt st uncntr,Long-term use of insulin,Pure hypercholesterolem,Drug dermatitis NOS,Adv eff cephalosporin
Admission Date:  [**2182-10-30**]              Discharge Date:   [**2182-11-26**]

Date of Birth:  [**2122-3-3**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Actos / Percocet / Cephalosporins

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Epigastric pain and shortness of breath

Major Surgical or Invasive Procedure:
Intubated
IABP
RIJ


History of Present Illness:
Mr. [**Known lastname **] is a 60 y.o male with a history of nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD who
presented to [**Hospital6 **] with epigastric chest
pain and shortness of breath. At [**Hospital1 487**], he was found to have
a left bundle branch block that was not known to be old and as
such was taken to the cath lab. The LBBB was later noted to be
old, however during cath he was noted to have a total occlusion
to the OM2 as well as 2 tight lesions in the RCA. Of note, the
patient had been found to have inferior septal ischemia on a
stress test during outpatient workup.
In the cath lab, the patient subsequently developed acute
shortness of breath, at which point he was given 100mg of lasix
and started on a nitroglycerin drip. His symptoms did not
improve, at which point he was intubated and an intra-aortic
balloon pump was placed through right femoral access. He also
received angiomax and 300mg of clopidogrel. A swan was placed
which showed elevated pulmonary artery pressures and wedge
pressures between 37-44. Laboratory exam at [**Hospital1 487**] was
significant for Na 129, K 4.1, BUN 53, Cr 1.3, hemoglobin 16.6
and platelets of 135. Her PT was 19.4 and INR was 1.8. Dig level
of 0.8, and cardiac enzymes significant for CK of 135, MB of 7
and Troponin of 0.08 which was negative in their reference
range.
.
Review of systems could not be obtained due to intubation.


Past Medical History:
CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.

-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceride
CHF
Afib
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]
.


Social History:
-Tobacco history: Former smoker
-ETOH: no etoh
Is not married.


Family History:
Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz


Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T=97.5 BP= 87/38 HR=89 RR=16 O2 sat=100% on 500/18/5/40
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CARDIAC: Fast, irregular, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diffusely rhonchorous with crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema. Right femoral sheath
introducer sheeth and swan in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial, DP 2+ bilaterally.
.

Pertinent Results:
Admission Labs:
[**2182-10-30**] 11:04PM BLOOD WBC-12.7* RBC-4.68 Hgb-15.5 Hct-44.1
MCV-94 MCH-33.1* MCHC-35.1* RDW-17.0* Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Neuts-83.9* Lymphs-10.4* Monos-4.5
Eos-0.6 Baso-0.6
[**2182-10-30**] 11:53PM BLOOD PT-33.4* PTT-150* INR(PT)-3.4*
[**2182-10-30**] 11:04PM BLOOD Plt Ct-157
[**2182-10-30**] 11:04PM BLOOD Glucose-243* UreaN-54* Creat-1.6* Na-133
K-4.4 Cl-96 HCO3-29 AnGap-12
[**2182-10-30**] 11:04PM BLOOD ALT-22 AST-31 LD(LDH)-313* CK(CPK)-126
AlkPhos-89 TotBili-0.3
[**2182-10-30**] 11:04PM BLOOD CK-MB-10 MB Indx-7.9* cTropnT-0.17*
[**2182-10-30**] 11:04PM BLOOD Calcium-7.9* Phos-5.3* Mg-1.9
[**2182-10-30**] 11:04PM BLOOD TSH-3.9
.
STUDIES:
CHEST (PORTABLE AP) Study Date of [**2182-10-30**]
Large right upper lobe opacity is consistent with a right upper
lobe collapse. The NG tube tip is in the distal right mainstem
bronchus. The aortic balloon pump tip is 2.4 cm from the aortic
arch. ET tube tip is 2.3 cm above the carina. Swan-Ganz catheter
from inferior approach is in the main right pulmonary artery.
Left transvenous pacemaker lead terminates in the standard
position in the right ventricle. There is moderate-to-severe
cardiomegaly.  Left perihilar and left upper lobe opacities
could be atelectasis or infection. There is gastric distention.

There is mild shifting of the cardiomediastinum towards the
right side.
.
Portable TTE (Complete) Done [**2182-10-31**]

Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF = 15
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with normal free wall contractility. The aortic valve
leaflets are mildly thickened (?#). There is mild aortic valve
stenosis (valve area 1.5 cm2). The aortic stenosis is likely the
"low flow/low gradient" type. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
.
CT Ab/Pelvis [**2182-11-13**]
1. Findings suggestive of mild-to-moderate pulmonary edema. More
focal small nodular opacities within the lungs as described
above may represent focal regions of underlying
pneumonitis/pneumonia, possibly aspiration related in this
patient with distal trachea secretions. Small right simple
pleural effusion. Follow up CT chest in [**4-13**] months recommended
to confirm nodular opacity resolution.

2. No definite source of infection noted within the
abdomen/pelvis. No
biliary ductal dilatation.

3. Moderate sized right piriformis collection, probably
intramuscular
hematoma, particularly in the setting of anticoagulation
(infected collection cannot be excluded).

4. Dense atherosclerotic calcifications involving the aorta and
coronary
tree. Cardiac enlargement dilatation of both the left ventricle
and left
atrium.
.
CARDIAC CATH [**2182-11-21**]
1.Selective coronary angiography in this right dominant system
demonstrated two vessel coronary artery disease.  The LMCA was
free of
angiographically-apparent disease.  The LAD was heavily
calcified with
mild luminal irregularities.  The LCx had a short total
occlusion in the
mid CX into the OM2 which filled via collaterals from the OM1
and LAD.
The RCA had severe diffuse calcific diesease with calcific
70-80%
stenoiss in the proximal vessel, distal 50% stenosis adn 99%
calcific
stenosis at the RPDA/RPL bifurcation.
2.Resting hemodynamics revealed normal right and left sided
filling
presures with RVEDP 13 mmHg and PCWP 12 mHg.  The cardiac index
was
preserved at 2.6 l/min/m2.  There was mild systolic hypotension
SBP 87
mmHg.
3. Left ventriculography was deferred.
4. Successful PCI of RCA lesions with rotablation and DES via R
radial
approach and balloon pump support
5. Unsuccessful PCI of the OM.
6. Secondary prevention of CAD
7. Plavix 75mg daily for 12 months
8. Monitor for signs of left leg ischemia
9. Follow creatinine and HCT

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful PCI to RCA with rotablation and IABP support.
3. Unsuccessful PCI of the OM.
4. Successful removal of IABP.
.
DISCHARGE LABS:
Na 134, K 4.8, BUN 35, Creat 1.2, WBC 3.7, HCT 27, HGB 8.9, plt
116, INR 1.6
.
ECHO [**11-25**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. There is severe global left ventricular hypokinesis
with near akinesis of the inferior septum, inferior, and
inferolateral wall. The anterior wall and anterior septum
contracts best, but are hypokinetic. Global systolic function is
severely depressed. (LVEF = 20 %). No masses or thrombi are seen
in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There is mild aortic valve
stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are structurally normal. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.

Compared with the prior study (images unavailable for review) of
[**2182-10-31**], left ventricular systolic function is similar. Mild
mitral regurgitation is now seen.
.
Micro data: (unless noted positive, result is negative)
[**2182-11-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2182-11-12**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2182-11-9**] CATHETER TIP-IV WOUND CULTURE-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE
NEGATIVE} INPATIENT
[**2182-11-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram Stain-FINAL
INPATIENT
[**2182-11-8**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL INPATIENT
[**2182-11-7**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT
[**2182-11-7**] Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG
SEROLOGY-FINAL INPATIENT
[**2182-11-7**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG
AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **]
VIRUS VCA-IgM AB-FINAL INPATIENT
[**2182-11-7**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV
IgM ANTIBODY-FINAL INPATIENT
[**2182-11-6**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-6**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-5**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-11-3**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-11-1**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2182-10-31**] URINE URINE CULTURE-FINAL INPATIENT
[**2182-10-30**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT


Brief Hospital Course:
60 year old man who presented to an outside hospital emergency
room with epigastric pain and shortness of breath, who was
subsequently taken to the cath lab after being found to have a
LBBB which was later demonstrated to be old. The patient
subsequently became dyspneic in the cath lab, was intubated,
became hypotensive, and an IABP was placed with phenylephrine
started. He was subsequently transferred to the [**Hospital1 18**] CCU for
further care.
.
# Shock and Dyspnea: The patient initially had elevated
biventricular elevated filling pressures, increased cardiac
output and low SVR.  He was therefore thought to have
distributive shock with potential sepsis.  Our initial chest
x-ray after new OG tube placement showed a collapsed right upper
lobe of his lung which later resolved after replacement of the
OG tube.  He was pan-cultured and started on broad spectrum
antibiotics including Vancomycin and Zosyn, later switched to
Vancomycin, Cefepime, and Ciprofloxacin.  His pressors remained
marginal, and he required levophed to maintain MAPs >65.  Due to
persistently adequate cardiac output readings from his Swan, his
intra-aortic balloon pump and Swan were removed.  Repeat chest
x-rays showed pulmonary edema and acute exacerbation of his
systolic congestive heart failure. Extubation was attempted on
[**2182-11-1**], but afterwards his oxygenation decreased acutely most
likely secondary to flash pulmonary edema.  He failed a trial of
BiPAP and became acutely agitated, requiring emergent
re-intubation.  He was subsequently aggressively diuresed with
IV boluses of furosemide in addition to a furosemide drip with
metolazone. After the initial diuresis, he was transitioned to
Torsemide PO and developed hyponatremia. The Torsemide dose was
adjusted to 10 mg and he appears to be at his dry weight today
of 200 pounds. He is ambulating on RA with O2 sats in high 90's,
no peripheral edema and clear lung sounds. Given his very low
EF, he should be started in spironolactone and digoxin as his BP
allows. Please weight daily and adjust diuretics to maintain
weight at 200 pounds. He is being considered for a heart
transplant and transplant workup was started during this
hospital stay. He will follow up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP here for continued workup and evaluation.

.
# Coronary artery disease: The patient had evidence of a
reperfusion defect on recent SPECT stress test and evidence of
tight lesions in RCA from his cardiac catheterization at the
outside hospital. His troponins were mildly elevated which could
have represented demand ischemia and/or congestive heart
failure, but less likely acute coronary syndrome.  His ECG
showed a LBBB that remained unchanged throughout his CCU stay.
He was medically managed with 48 hours of a heparin drip, full
dose aspirin, atorvastatin 40mg daily, loaded with 300mg plavix
and then given plavix 75mg daily.  He underwent catheterization
prior to discharge with stenting of an RCA lesion (see cath
report.) Note that in the setting of a heparin gtt, the patient
developed a piriformis hematoma; his HCT remained stable.
.
# Atrial fibrillation and Ventricular Tachycardia: The patient
was persistently in atrial fibrillation and had several episodes
of ventricular tachycardia prompting firing of his ICD.  His
beta blocker was held secondary to his hypotension requiring
pressors.  He was seen by our electrophysiology team and
received a AV nodal ablation following by a BiV pacer upgrade.
He has been restarted on his betablocker at a lower dose and
amiodarone was loaded. He has had no further VT within the last
4-5 days and he is [**Age over 90 **]% AV paced on telemetry.
.
# Acute renal failure: This was most likely secondary to poor
forward flow in the setting of an acute on chronic systolic CHF
exacerbation.  His lisinopril was held, medications were renally
dosed and his renal function improved with diuresis. ACEi was
restarted before discharge at lower dose.
.
# Diabetes mellitus type 2: The patient was maintained on
glargine and an ISS without complications. Metformin was d/c'ed
because of his CHF. His glargine may need to be uptitrated as
his appetite improves. Please continue to do fingerstickes
before meals with Humalog insulin coverage per sliding scale.
.
#Transaminitis: LFTs trending down. Thought to be secondary to
poor forward flow with CHF exacerbation. Statin has been
restarted.
.
# Anemia: Hct has slowly trended down during hospital stay. He
has no evidence of acute bleeding at present and piriformis
hematoma development did not seem to drop his hct precipitously.
It is thought that anemia a combination or phlebotomy, ARF and
critical illness. His hct should be monitored and iron studies
sent if hct/hgb continues to drop. Stools should be Guiaiced.
.
# Hyponatremia: now resolved. Thought secondary to overdiuresis.
Torsemide dose has been adjusted and should be titrated to
maintain dry weight of 200 pounds.
.
# Social: Patient lives alone with an elderly aunt and uncle as
[**Name2 (NI) **] supports.He was functionally independent before admission
and goal is to return to this.


Medications on Admission:
Home medications
Aspirin 81mg daily
lipitor 40mg daily
lisinopril 40mg qd
lopressor 150mg [**Hospital1 **]
digoxin 0.375mg MWF, 0.25mg TTSS
furosemide 160mg [**Hospital1 **]
metolazone 2.5 qweek
Gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lantus 48 units qd
multivitamin
coumadin 5mg TWFSS, 7.5mg MT


Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not skip doses or stop taking unless Dr. [**Last Name (STitle) **] says
it is OK.
Disp:*30 Tablet(s)* Refills:*11*
6. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. torsemide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 70.
11. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
12. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: before meals.
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X per week
(Sun, Tues, Wed, Fri): Please check INR on Thursday [**11-28**].
14. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 3X/week
(Mon, Thurs, Sat).
15. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient Lab Work
[**Last Name (un) 6267**] check IR, PT, CBC and Chem 7 on [**2182-11-28**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Atrial fibrillation s/p AV node ablation
Acute on chronic systolic congestive heart failure
Anemia
Hypothyroidism
Ventricular Tachycardia


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


Discharge Instructions:
It was a pleasure to take care of you in the hospital. You were
admitted for heart failure and required a lengthy stay in the
ICU. During your time in the ICU you were intubated and had
pneumonia. Also, three important procedures were performed.
First, you had an AV nodal ablation which allowed your heart to
beat more slowly. Second, you had a revision to your pacer to
help your heart work better. Finally, you had a catheterization
of your heart during which stents were placed to open blocked
vessels.

You should make the following changes to your medications:
CHANGE THE FOLLOWING DOSES:
- Change aspirin 81 mg daily to aspirin 325 mg daily
- Change Lisinopril 40 mg daily to Lisinopril 5 mg daily
- Change Metoprolol 150 mg [**Hospital1 **] to Toprol XL 12.5 mg daily
- Change Furosemide to torsemide 10 mg daily

STOP THE FOLLOWING MEDICATIONS:
- Digoxin, Metolozone, metformin, spironolactone

START THE FOLLOWING NEW MEDICATIONS:
- Plavix to keep the stents open. You will need to take this
medicine every day for at least one year with a 325 mg aspirin.
Do not stop taking these medicines unless Dr. [**First Name (STitle) 437**] tells you it
is OK.
- Start Amiodarone to control your heart rhythm
- Start Trazadone to help you sleep
- start senna as needed if you get constipated.
- Ranitidine to protect your stomach from the Plavix and
aspirin.

Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.

Please go to all of the recommended followup appointments that
are listed below.

Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2182-12-16**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please call Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 63252**] when you get out of
rehab to schedule appts.



Completed by:[**2182-11-27**]
{'Acute on chronic systolic heart failure,Unspecified septicemia,Septic shock,Severe sepsis,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Ventilator associated pneumonia,Other primary cardiomyopathies,Candidiasis of mouth,Chronic total occlusion of coronary artery,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified hereditary and idiopathic peripheral neuropathy,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Nontoxic multinodular goiter,Other left bundle branch block,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pure hypercholesterolemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use'}


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: Epigastric pain and shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 y.o male with a history of nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD who
presented to [**Hospital6 **] with epigastric chest
pain and shortness of breath. At [**Hospital1 487**], he was found to have
a left bundle branch block that was not known to be old and as
such was taken to the cath lab. The LBBB was later noted to be
old, however during cath he was noted to have a total occlusion
to the OM2 as well as 2 tight lesions in the RCA. Of note, the
patient had been found to have inferior septal ischemia on a
stress test during outpatient workup.
In the cath lab, the patient subsequently developed acute
shortness of breath, at which point he was given 100mg of lasix
and started on a nitroglycerin drip. His symptoms did not
improve, at which point he was intubated and an intra-aortic
balloon pump was placed through right femoral access. He also
received angiomax and 300mg of clopidogrel. A swan was placed
which showed elevated pulmonary artery pressures and wedge
pressures between 37-44. Laboratory exam at [**Hospital1 487**] was
significant for Na 129, K 4.1, BUN 53, Cr 1.3, hemoglobin 16.6
and platelets of 135. Her PT was 19.4 and INR was 1.8. Dig level
of 0.8, and cardiac enzymes significant for CK of 135, MB of 7
and Troponin of 0.08 which was negative in their reference
range.
.
Review of systems could not be obtained due to intubation.

MEDICAL HISTORY: CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.

MEDICATION ON ADMISSION: Home medications
Aspirin 81mg daily
lipitor 40mg daily
lisinopril 40mg qd
lopressor 150mg [**Hospital1 **]
digoxin 0.375mg MWF, 0.25mg TTSS
furosemide 160mg [**Hospital1 **]
metolazone 2.5 qweek
Gemfibrozil 600mg [**Hospital1 **]
metformin 1000mg [**Hospital1 **]
lantus 48 units qd
multivitamin
coumadin 5mg TWFSS, 7.5mg MT

ALLERGIES: Penicillins / Actos / Percocet / Cephalosporins

PHYSICAL EXAM: PHYSICAL EXAMINATION on Admission:
VS: T=97.5 BP= 87/38 HR=89 RR=16 O2 sat=100% on 500/18/5/40
GENERAL: Intubated, sedated.
HEENT: NCAT. Sclera anicteric. PERRL, Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
CARDIAC: Fast, irregular, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Diffusely rhonchorous with crackles throughout.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace lower extremity edema. Right femoral sheath
introducer sheeth and swan in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Radial, DP 2+ bilaterally.
.

FAMILY HISTORY: Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz

SOCIAL HISTORY: -Tobacco history: Former smoker
-ETOH: no etoh
Is not married. 

### Response:
{'Acute on chronic systolic heart failure,Unspecified septicemia,Septic shock,Severe sepsis,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Paroxysmal ventricular tachycardia,Hyperosmolality and/or hypernatremia,Ventilator associated pneumonia,Other primary cardiomyopathies,Candidiasis of mouth,Chronic total occlusion of coronary artery,Bacteremia,Infection and inflammatory reaction due to other vascular device, implant, and graft,Unspecified hereditary and idiopathic peripheral neuropathy,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Nontoxic multinodular goiter,Other left bundle branch block,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pure hypercholesterolemia,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use'}
