CHIEF COMPLAINT: "Cardiogenic Shock, CHF, Critical AS"

PRESENT ILLNESS: 71-year-old man with AS undergoing CoreValve eval for critical
aortic stenosis, s/p complicated cardiac cath on [**7-10**] (hematoma)
groin p/w with CP and SOB s/p Intubation

MEDICAL HISTORY: -Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

MEDICATION ON ADMISSION: 1. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Unasyn

PHYSICAL EXAM: Admission Exam
T 97.2 BP 134/53 HR 63 RR 18 96% RA
[**7-25**]: Tm 99.0 BP 104-134/61-71 HR 78-99 RR 16-18% RA
Gen: NAD, intubated, sedate. Responded to questions, squeezed
hand.
HEENT: NCAT PERRLA, intubated
Resp: Lungs rhonchorous with diffusely decrease sounds,
crackles.
CV: Tachy, S1/S2, [**4-14**] holosystolic murmur that radiates to
carotids.
Abd: Soft, non-tender, protuberant, bowel sounds positive. No
tenderness to palpation.
EXT: slighlty mottled L>R leg, thready DP bilaterally. Edematous
(mild pitting)
.
DISCHARGE EXAM:
Temp current: 98.4  HR: 80-81 RR: 18 BP: 128-132/44-64  O2 Sat:
98% RA
Gen: NAD, appears comfortable
HEENT: NCAT, MMM, no JVP elevation
CV: RRR, crescendo/decrescendo murmur at RUSB
Resp: CTAB anteriorly and upper post
Abd: soft, NT/ND, pos BS
Ext: no LE edema, DP pulses 2+
Neuro: moves all extremities, follows commands, responds with
yes/no
Skin: warm, dry, no open areas noted (back not assessed)

FAMILY HISTORY: There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.
Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Dissection of carotid artery,Cardiogenic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Bacteremia,Aphasia,Chronic kidney disease, Stage III (moderate),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Atrial fibrillation,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Aortic valve disorders,Infection with microorganisms without mention of resistance to multiple drugs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atherosclerosis of native arteries of the extremities, unspecified,Paralysis agitans,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to indwelling urinary catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified antibiotics causing adverse effects in therapeutic use
Ac on chr syst hrt fail,Ac kidny fail, tubr necr,Acute respiratry failure,Dissect carotid artery,Cardiogenic shock,Crbl art ocl NOS w infrc,Bacteremia,Aphasia,Chr kidney dis stage III,Enterococcus group d,Atrial fibrillation,Ac posthemorrhag anemia,Hyperosmolality,Aortic valve disorder,Inf mcr rst ot drg nt ml,DMII wo cmp nt st uncntr,Athscl extrm ntv art NOS,Paralysis agitans,Hy kid NOS w cr kid I-IV,Iatrogen CV infarc/hmrhg,React-indwell urin cath,Abn react-procedure NEC,Adv eff antibiotics NEC
Admission Date:  [**2120-7-30**]              Discharge Date:   [**2120-8-15**]

Date of Birth:  [**2049-3-15**]             Sex:   M

Service: MEDICINE

Allergies:
Unasyn

Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
"Cardiogenic Shock, CHF, Critical AS"

Major Surgical or Invasive Procedure:
Cardiac catheterization
Attempted balloon angioplasty
CVVH
Intubation

History of Present Illness:
71-year-old man with AS undergoing CoreValve eval for critical
aortic stenosis, s/p complicated cardiac cath on [**7-10**] (hematoma)
groin p/w with CP and SOB s/p Intubation

Was at rehab after [**Hospital1 18**] admission (see below). On [**7-28**] he was
combative, delirious. On [**7-29**] he c/o CP and SOB. Sent to NVMC ED
with t98.3, HR 108, RR 18, BP 117/47, 84% on RA. He received
60mg IV lasix and BiPap. Admitted to a telemetry float. IV dapto
(600) and Gent (120) given. On [**7-30**], at 0120, he received 40mg
IV lasix for SOB and was intubated at 2am and started on
propofol. No vasopressors. CXR with "extensive fluffy
infiltrates that appeared nodular". ABG showed 7.35/40/94 on
100%Fi02, PEEP 5, TV 700 on AC at RR12. Net fluid balance was
800 negative. Cultures were drawn. WBC 6.7, Hbg 9.3, HCT 26.3,
plt 312. Na 132, K 3.6, Cl 94, HCO3 26, BUN 33, Cr 2.28 (from
1.86 overnight. ACE and BB were held due to "soft" blood
pressures. He was transferred to the [**Hospital1 18**] CCU intubated on
propofol.

In the CCU, he was tachy to 130 and hypotensive to 90's. His CXR
yielded a diffuse patchy infiltrate. His PICC line transduced a
CVP of 9. He received 2.5 mg of metoprolol tartrate to bring
rate to 100. EKG was unchanged despite rate decrease with
precordial ST-depressions, AVR elevation. He received 500cc of
NS bolus (250 x 2). Propofol was dc'd.

LAST ADMISSION
Was admitted on [**7-10**] with Hematoma following cardiac
catheterization which disclosed RCA disease. He had ecchymoses
throughout right  groin, including swelling and discoloration of
genitals. Ultrasound revealed pseudoaneurysm of the femoral
artery with bleeding resolved by thrombin injection, confirmed
by US. The patient developed fever on [**2120-7-15**] and increased
oxygen requirement. 8/8 bottles were growing Enterococcus
faecalis as was his urine. TTE was without vegetation. He was
treated as endocarditis.  WBC scan showed a single focus near
posterior liver, may also be in pleural space, but no reason to
believe AAA graft was infected by scan. Infectious Disease was
consulted and started patient on regimen of daptomycin (patient
had anaphylaxis to Unasyn) and gentamicin. Within 48 hours, the
patient had defeveresced. His blood cultures from [**2120-7-16**] onward
were negative.

ASSORTED PROBLEMS DURING LAST ADMISSION
During an episode of oxygen desaturation, an EKG was checked,
which showed no ST or T wave changes. The patient had troponin
elevation (0.57), but CK-MB (2) resolved. Patient's Cr rose to
1.6 from 1.2 and later fell to 1.3 on discharge. Cardiac surgery
has declined AV replacement. Patient underwent CTA chest/CT
cardiac and PFTs as part of CoreValve work-up. Episodes of
abdominal pain with negative bloodtests. RUQ ultrasound ordered
for unclear indications and showed cholelithiasis without
cholecystitis.

Past Medical History:
-Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

Social History:
He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.


Family History:
There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

Physical Exam:
Admission Exam
T 97.2 BP 134/53 HR 63 RR 18 96% RA
[**7-25**]: Tm 99.0 BP 104-134/61-71 HR 78-99 RR 16-18% RA
Gen: NAD, intubated, sedate. Responded to questions, squeezed
hand.
HEENT: NCAT PERRLA, intubated
Resp: Lungs rhonchorous with diffusely decrease sounds,
crackles.
CV: Tachy, S1/S2, [**4-14**] holosystolic murmur that radiates to
carotids.
Abd: Soft, non-tender, protuberant, bowel sounds positive. No
tenderness to palpation.
EXT: slighlty mottled L>R leg, thready DP bilaterally. Edematous
(mild pitting)
.
DISCHARGE EXAM:
Temp current: 98.4  HR: 80-81 RR: 18 BP: 128-132/44-64  O2 Sat:
98% RA
Gen: NAD, appears comfortable
HEENT: NCAT, MMM, no JVP elevation
CV: RRR, crescendo/decrescendo murmur at RUSB
Resp: CTAB anteriorly and upper post
Abd: soft, NT/ND, pos BS
Ext: no LE edema, DP pulses 2+
Neuro: moves all extremities, follows commands, responds with
yes/no
Skin: warm, dry, no open areas noted (back not assessed)

Pertinent Results:
ADMISSION LABS:
[**2120-7-30**] WBC-9.8# RBC-3.55* Hgb-10.5* Hct-30.9* MCV-87 MCH-29.4
MCHC-33.8 RDW-14.2 Plt Ct-557*#
Neuts-75* Bands-1 Lymphs-18 Monos-4 Eos-0 Baso-0 Atyps-1*
Metas-0 Myelos-1*
PT-14.3* PTT-27.9 INR(PT)-1.2*
Glucose-204* UreaN-40* Creat-2.7*# Na-137 K-4.2 Cl-95* HCO3-27
AnGap-19
Calcium-8.5 Phos-7.6*# Mg-2.2
Gentamycin-5.5
Type-ART pO2-51* pCO2-65* pH-7.23* calTCO2-29 Base XS--1
Lactate-3.0*

[**2120-7-31**] WBC-5.5 RBC-3.38* Hgb-9.7* Hct-29.4* MCV-87 MCH-28.8
MCHC-33.1 RDW-14.2 Plt Ct-595*
Glucose-270* UreaN-51* Creat-2.9* Na-134 K-4.9 Cl-97 HCO3-23
AnGap-19
Glucose-298* UreaN-63* Creat-3.7* Na-131* K-4.5 Cl-94* HCO3-19*
AnGap-23*
CK-MB-3 cTropnT-0.13*
Calcium-8.0* Phos-6.8* Mg-2.2
Lactate-6.7*

[**2120-8-1**] 04:00AM BLOOD WBC-6.4 RBC-2.91* Hgb-8.6* Hct-25.0*
MCV-86 MCH-29.7 MCHC-34.6 RDW-14.5 Plt Ct-483*
ALT-447* AST-685* AlkPhos-56 TotBili-0.7

[**2120-8-2**] Gentamycin-0.5*

[**2120-8-4**] Lactate-1.8

[**2120-8-8**] ALT-51* AST-34 LD(LDH)-278* AlkPhos-73 TotBili-0.3

DISCHARGE LABS:
[**2120-8-13**] WBC-7.5 RBC-3.89* Hgb-10.9* Hct-34.8* MCV-90 MCH-28.1
MCHC-31.4 RDW-17.1* Plt Ct-406
Glucose-205* UreaN-54* Creat-2.3* Na-140 K-4.1 Cl-104 HCO3-27
AnGap-13
Calcium-8.6 Phos-4.1 Mg-2.3

[**2120-8-14**] WBC-8.1 RBC-3.79* Hgb-10.5* Hct-33.8* MCV-89 MCH-27.8
MCHC-31.2 RDW-17.0* Plt Ct-452*
Glucose-176* UreaN-49* Creat-2.4* Na-140 K-4.5 Cl-104 HCO3-26
AnGap-15
Calcium-8.7 Phos-3.6 Mg-2.3

[**2120-8-15**]  WBC-9.3 RBC-4.03* Hgb-11.3* Hct-35.9* MCV-89 MCH-28.1
MCHC-31.6 RDW-16.9* Plt Ct-464*
PT-26.9* PTT-30.5 INR(PT)-2.6*
Glucose-158* UreaN-38* Creat-2.0* Na-142 K-4.1 Cl-108 HCO3-28
AnGap-10
Calcium-8.7 Phos-3.6 Mg-2.2

MICROBIOLOGY:

BLOOD CULTURE      Source: Line-PICC.
Blood Culture, Routine (Final [**2120-8-5**]):    NO GROWTH.

SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2120-7-30**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2120-8-1**]):
      SPARSE GROWTH Commensal Respiratory Flora.

STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2120-7-31**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

URINE      Source: Catheter.
   URINE CULTURE (Final [**2120-8-6**]):
      PROTEUS MIRABILIS.    PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------     8 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------     4 S
TRIMETHOPRIM/SULFA----   <=1 S

IMAGING
TTE ([**2120-7-31**]):
FOCUSED VIEWS PRE/POST AORTIC VALVULOPLASTY. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. No aortic regurgitation is seen prior to
valvuloplasty. Mild (1+) aortic regurgitation is seen after
valvuloplasty. There is moderate thickening of the mitral valve
chordae. Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.

KUB ([**2120-8-7**]):
1. No evidence of obstruction or ileus.
2. No evidence of free air on these supine radiographs.

CT HEAD ([**2120-8-8**])
IMPRESSION: Left parietal hypodensity extends to the cortex and
has an
appearance of subacute infarct of few days' duration. However,
clinical
correlation recommended. No hemorrhage seen

EEG ([**2120-8-9**])
IMPRESSION: This is an abnormal EEG due to the presence of a
background
frequency asymmetry suggesting a large area of subcortical
abnormality
involving the left hemisphere. Additionally, the presence of a
slower
than normal background with bursts of generalized slowing is
consistent
with a mild to moderate encephalopathy of toxic, metabolic, or
anoxic
etiology.

CTA HEAD/NECK ([**2120-8-11**])
IMPRESSION: Subacute-appearing infarct with some blood products
in the left parietal lobe. No acute infarct is seen. No mass
effect or hydrocephalus.  Note is made of decreased flow void in
the right cavernous carotid artery.
IMPRESSION: Right internal carotid artery has markedly
diminished flow. The internal carotid was described to be normal
on a previous duplex ultrasound on [**2120-7-15**]. Axial source images
do not give appearance of a dissection, but further evaluation
with CTA is recommended after consideration of patient's renal
insufficiency.
MPRESSION: Diminished flow signal in the right cavernous and
petrous carotid could be due to occlusion or markedly slow flow.


CAROTID U/S ([**2120-8-13**])
Right - nice brisk upstoke, minimal diastolic flow, diminuitive
ICA and potential dissection versus intracranial carotid
disease- CTA and clinical correlation is suggested.


Brief Hospital Course:
71 M with AS (0.8) and One vessel CAD p/w resp. distress that
prompted intubation. He is presently hypotensive, tachycardic
and profoundly hypoxic.
.
ACUTE ISSUES:
# Hypoxia - Patient arrived intubated after presenting to OSH
with SOB. Bilateral pulm infiltrates were severe and most
radiologically c/w pulm edema. However, the patient had fluid
responsive tachycardia and a low CVP (through the PICC). His
resp distress progressed despite lasix diuresis at NVMC.
Accordingly, initial differential included ARDS from sepsis (see
below), DAD, multifocal pna, flash pulmonary edema and
daptomycin pneumonitis. He was ventilated with ARDSnet settings.
 Pt was able to be weaned to minimal ventilator settings by day
8 of intubation.  However, extubation was delayed due to pt's
mental status.  Despite holding sedation for several days, pt
remained non-responsive.  He was successfully extubated on day
11 of intubation.  He successfully transitioned from nasal
canula to room air and has an oxygen saturation of 97-100% on
room air at time of discharge.
.
# Hypotension - Inital presentation with low CVP implies poor
preload implicating aortic stenosis as a cause. Tachycardia
improved with fluid boluses supporting poor preload.
Differential also included cardiac event, sepsis, PEEP effect
and propofol. Fluids and pressors were administered with goal
MAP > 60. Palliative valvuloplasty was attempted. TTE showed
post-valvuloplasty aortic valve area of 0.8cm2. He was
pan-cultured and initially continuted on vancomycin (gentomycin
was held given [**Last Name (un) **]).  He was successfully weaned off pressors
and maintained MAP >65.
.
# E. Faecalis infection:  Pt diagnosed with E.Faecalis on
previous admission and was discharged on dapto/gentamycin.  In
interim, pt developed [**Last Name (un) **] that was attributed to gentamycin
toxicity.  Dapto/gent was discontinued and he was started on
vancomycin (vanc sensitivity MIC of 2). Infectious Disease team
was consulted and per their recommendations, vancomycin was
discontinued due to risk of increasing kidney injury.  Pt was
resumed again on daptomycin.  Blood cultures remained negative
during this hospitalization.  He is to complete a 6 week course
of daptomycin for bacteremia (should be discontinued around
[**2120-8-28**] - however exact date of discontinuation should decided
at follow-up ID appointment on [**2120-8-20**]).
.
# UTI: Pt developed fever and leukocytosis during his ICU stay.
A UA demonstrated pyuria, and he grew Proteus resistant to cipro
but sensitive to ceftriaxone. He was started on ceftriaxone 1gm
daily for a 14 day course which should be completed on [**2120-8-29**].
.
# Atrial Fibrillation:  Pt developed new onset paroxysmal atrial
fibrillation during hospitalization with heart rates up to 150s.
 He was rate controlled with IV and PO metoprolol.  He was
loaded with amiodarone and was started on anticoagulation with
heparin and coumadin.  He spontaneously converted back to sinus
rhythm and has remained in sinus for several days without any
recurrence of afib.  He was taken off heparin drip once INR was
theraputic at 2.0-3.0. He should be continued on amio 400 mg PO
daily for 1 week, and then decreased to maintenance dose of amio
200 mg PO daily.  His INR has been theraputic on coumadin 5mg PO
daily.
.
# Renal Failure - Pt presented with acute renal failure, thought
to be secondary to gentamicin use with a creatinine that peaked
at 3.7. Pt' severe respiratory distress was thought to be due to
volume overload so CVVH was initiated.  There were issues of
kinking with the CVVH catheter and the line had to be replaced
two times in order to achieve adequate flow. Pt tolerated CVVH
well with only one episode of hypotension thought to be related
to excessive fluid shifts during the CVVH. CVVH was discontinued
on [**8-5**] when pt began putting out good urine to IV Lasix. By the
end of his stay, pt was euvolemic, his creatinine was trending
down and he no longer required lasix.
.
# Altered Mental Status/Stroke - There was difficulty extubating
patient due to persistent mental status alteration. He was
inconsistently responsive to painful stimuli and failed to
respond to simple commands even though he had been quite alert
and interactive prior to his hospitalization. This altered
mental status was initially attributed to oversedation during
intubation so sedation was withheld for several days without any
improvement in mental status. Concern was then raised for
ischemic stroke given his recent episodes of atrial fibrillation
(see below). On exam, it was noticed that he seemed to had
clonus on his right side and appeared to have gaze preference to
the left. Neurology was consulted who recommended a CT Head and
MRI/MRA of the Head. CT Head showed left parietal hypodensity
extending to the cortex with an appearance of subacute infarct
of few days' duration. Follow-up MRI/MRA confirmed these
findings but also showed diminished flow in the right ICA. F/u
ultrasound of the carotids demonstrated intracranial dissection
on the right but per vascular surgery, no intervention is needed
and he can follow-up with vascular surgery in six months for
interval evaluation of any changes. However, he should be
further evaluated with CTA once his renal function improves.
Most likely etiology of the stroke is thrombus dislodged during
valvuloplasty or during pt's episodic episodes of atrial
fibrillation. After patient was successfully extubated, his
mental status improved significantly. He was alert and able to
follow commands consistently. He had a tremor in his face and
extremities (though this was present at baseline) and pt has an
expressive aphasia, able to answer questions only in short
sentences. Per neurology, pt is now exhibiting symptoms of
Parkinsonism but would defer treatment at this point.
.
# Diabetes: Pt continue to have elevated BG to 300s during ICU
stay.  He required insulin drip to manage his sugars.  [**Hospital **]
Clinic was consulted and pt was started on Lantus 45 units along
with sliding scale insulin as attached.
.
CHRONIC ISSUES:
# Aortic stenosis: Prior to admission pt was being evaluated for
CoreValve procedure, however evalution was complicated by
enterococcus infection.  Because of hypotension on presention,
palliative valvuloplasty was attempted but was not successful
because of technical difficulties.  Post-valvuloplasty aortic
area was 0.8cm2.  Volume status was monitored closely during
admission because pt is very preload depended.  Even if deemed
an appropriate candidate, he will not be eligable for CoreValve
for at least 6 months now given acute CVA.
.
# CAD: Pt continued on aspirin, metoprolol, and rosuvastatin
during hospitalization.
.
# Hypertension: Pt resumed on metoprolol once hypotension
resolved.
.
# Hyperlipidemia: Continue Rosuvastatin
.
TRANSITIONAL ISSUES:
He remained full code this admission.  Acute parietal infarct
has left pt with many residual deficits and will require intense
rehab and close follow-up with many specialties.

Medications on Admission:
1. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. oxazepam 10 mg TID
3. Klor-Con 10 10 mEq qd
4. gabapentin 800 mg TID
5. metoprolol tartrate 50 mg [**Hospital1 **]
6. rosuvastatin 5 mg daily
7. glimepiride 4 mg Tablet Sig: One (1) Tablet PO daily ().
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. docusate sodium 100 mg [**Hospital1 **]
10. insulin aspart sliding scale
(GENT AND DAPTO)

Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: [**2-11**]  PO BID (2 times a
day).
3. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1)  Intravenous Q24H (every 24 hours).
10. daptomycin 500 mg Recon Soln Sig: Six Hundred (600) mg
Intravenous Q24H (every 24 hours).
11. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
12. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

13. insulin glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous once a day: at lunch.
14. oxazepam 10 mg Capsule Sig: Ten (10) mg PO three times a day
as needed for anxiety.
15. gabapentin 800 mg Tablet Sig: One (1) Tablet PO twice a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Acute renal failure requiring CVVH
Acute respiratory distress requiring intubation
Stroke
Critical Aortic Stenosis
Urinary Tract Infection


Discharge Condition:
Mental status: minimally interactive due to expressive aphasia
Level of Consciousness: alert
Ambulatory: out of bed with assistance


Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were
hospitalized for acute shortness of breath likely related to an
antibiotic you were taking that lead to acute kidney injury. You
required intubation, mechanical ventilation, and initiation of
hemodialysis. You were also found to have suffered a stroke
during your hospitalization for which you will need rehab.
.
Please call your doctor if you notice any increased shortness of
breath or notice any weight gain.
.
Please note that you are currently taking antibiotics for an
infection in your urine and an infection in your blood. Stop
taking the daptomycin on [**8-28**] and stop taking the Ceftriaxone
on [**8-18**].
.
The following medications were changed during your
hospitalization:
1. Stop taking Aspirin 325mg and instead take Aspirin 81mg by
mouth daily.
2. Stop taking lasix.
3. Continue taking oxazepam 10mg by mouth up to 3 times a day
for anxiety
4. Stop taking gabapentin 800 mg three times a day and instead
take 800mg by mouth twice a day.
5. Stop taking glimepiride and instead take Lantus 45 units with
sliding scale insulin following scale provided.
6. Continue taking Daptomycin 600 mg IV daily  - end date to be
set during ID appointment on [**8-20**]
7. Continue taking CeftriaXONE 1 gm IV daily until [**2120-8-29**]
8. Take amiodarone 400mg daily for 1 week, then decrease to 200
mg by mouth daily.
9. take coumadin 5mg by mouth daily


Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2120-8-20**] at 2:30 PM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
.
Department: CARDIAC SERVICES
When: FRIDAY [**2120-8-23**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Also, please set-up follow up appointments with neurology (Dr.
[**Last Name (STitle) **] at [**Telephone/Fax (1) 2574**]) for your stroke, and [**Last Name (un) **] (Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 12648**]) for your diabetes, renal (Dr. [**Last Name (STitle) 14005**] at
[**Telephone/Fax (1) **]) for your kidney and Dr. [**Last Name (STitle) 1391**] (Vascular
Surgery)at [**Telephone/Fax (1) 1393**] for your carotid artery disease.
{'Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Dissection of carotid artery,Cardiogenic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Bacteremia,Aphasia,Chronic kidney disease, Stage III (moderate),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Atrial fibrillation,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Aortic valve disorders,Infection with microorganisms without mention of resistance to multiple drugs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atherosclerosis of native arteries of the extremities, unspecified,Paralysis agitans,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to indwelling urinary catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified antibiotics 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: "Cardiogenic Shock, CHF, Critical AS"

PRESENT ILLNESS: 71-year-old man with AS undergoing CoreValve eval for critical
aortic stenosis, s/p complicated cardiac cath on [**7-10**] (hematoma)
groin p/w with CP and SOB s/p Intubation

MEDICAL HISTORY: -Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

MEDICATION ON ADMISSION: 1. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Unasyn

PHYSICAL EXAM: Admission Exam
T 97.2 BP 134/53 HR 63 RR 18 96% RA
[**7-25**]: Tm 99.0 BP 104-134/61-71 HR 78-99 RR 16-18% RA
Gen: NAD, intubated, sedate. Responded to questions, squeezed
hand.
HEENT: NCAT PERRLA, intubated
Resp: Lungs rhonchorous with diffusely decrease sounds,
crackles.
CV: Tachy, S1/S2, [**4-14**] holosystolic murmur that radiates to
carotids.
Abd: Soft, non-tender, protuberant, bowel sounds positive. No
tenderness to palpation.
EXT: slighlty mottled L>R leg, thready DP bilaterally. Edematous
(mild pitting)
.
DISCHARGE EXAM:
Temp current: 98.4  HR: 80-81 RR: 18 BP: 128-132/44-64  O2 Sat:
98% RA
Gen: NAD, appears comfortable
HEENT: NCAT, MMM, no JVP elevation
CV: RRR, crescendo/decrescendo murmur at RUSB
Resp: CTAB anteriorly and upper post
Abd: soft, NT/ND, pos BS
Ext: no LE edema, DP pulses 2+
Neuro: moves all extremities, follows commands, responds with
yes/no
Skin: warm, dry, no open areas noted (back not assessed)

FAMILY HISTORY: There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Dissection of carotid artery,Cardiogenic shock,Cerebral artery occlusion, unspecified with cerebral infarction,Bacteremia,Aphasia,Chronic kidney disease, Stage III (moderate),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Atrial fibrillation,Acute posthemorrhagic anemia,Hyperosmolality and/or hypernatremia,Aortic valve disorders,Infection with microorganisms without mention of resistance to multiple drugs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atherosclerosis of native arteries of the extremities, unspecified,Paralysis agitans,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to indwelling urinary catheter,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified antibiotics causing adverse effects in therapeutic use'}
