CHIEF COMPLAINT: Acute exacerbation of CHF

PRESENT ILLNESS: 68 year old man with CAD s/p CABG [**2154**] (LIMA-LAD, SVG-D1/D3,
SVG-OM3), followed by repeat CABG [**2176**] in setting of MVR for
severe MR (SVG-RCA, SVG-SVG-OM3), CHF with EF 10%, VT s/p
BiV-ICD placement [**2172**], HIT, OSA, HTN, and DM, recently admitted
[**Date range (3) 106793**] and again [**Date range (3) 106794**] with acute on chronic
CHF exacerbation for aggressive diuresis. He presented with
probable acute volume overload, hyperkalemia and azotemia and
was admitted to [**Hospital1 1516**] cardiology service. Patient had cardiac
catheterization today ([**2179-9-1**]) for assessment of worsening CHF
with focal wall motion abnormalities on most recent
echocardiogram. He was transferred to the CCU service for
management of CHF and worsening renal function, requiring
continuous [**Last Name (un) **]-venous dialysis (CVVD), not currently on
dialysis.
.
Mr. [**Known lastname **] [**Last Name (Titles) **] Dr. [**Last Name (STitle) **] yesterday because he has developed
dyspnea and has gained 5 lbs. He otherwise is feeling OK. He was
advised to take 5 mg metolazone and increase his torsemide to
100 mg [**Hospital1 **]. Labs were checked this morning and returned: Na 131,
K 6.2, Cl 95, C02 26, BUN 104, Creatinine 3.4. Dr. [**Last Name (STitle) **] called
Mr. [**Known lastname 106795**] wife with these results and asked that he come into
the hospital, for direct admission to [**Hospital Ward Name 121**] 3. Since leaving home
he has been becoming increasingly breathless. He is happy to be
coming back sooner rather than later, because he really would
like to avoid dialysis (as with the last admission).
.
On night of [**2179-8-30**] he had been waking up every twenty minutes or
so with a jolt that he think originates from his ICD. He is on
monitored telemetry and sent samples last night. He typically
does not become breathless while lying flat, however he
presently feels that his ditended abdomen is preventing him from
breathing well.
.
Immediate relevant past medical history includes two
exacerbations of heart failure with volume overload in [**Month (only) 216**]
this year. During his admission (d/c date [**2179-8-2**]) several
liters were diuresed but this was limited by advancing azotemia
and low blood pressure. Despite diuresis being minimal he claims
to have felt less bloated and less dyspneic.
.
He stated that he was doing well after discharge until
8/17-18/09 when he started gaining weight and suffering
increased dyspnea, both on exertion and at rest. His goal intake
was 1200 mg or less of sodium and fewer calories per day. He
continued to use his BiPAP mask at night. However, he reported
gaining 6 pounds over two days with an increase in abdominal
girth/firmness. His weight was 224 pounds with a dry weight on
discharge [**2179-8-2**] of 216 pounds. He was admitted and he was
estimated as [**10-7**] kg above his dry weight. He was admitted to
the CCU where he was continued on lasix bolus and gtt, along
with milrinone bolus and gtt. He was continued on metolazone 5
mg [**Hospital1 **]. CVVH was started via R femoral line and continued for
several days until it clotted off. Through this time, patient
was continued on low dose neosynephrine as needed to support
blood pressure with goal MAP of 55. When CVVH line clotted off
([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone
with good UOP of 100-200 cc/hr. Patient was net -15 L fluid
removal on discharge.
.
During that admission, EP was contact[**Name (NI) **] about the possibility of
LV pacing, as patient has severe LV/RV dysynchrony on echo. It
was felt that given his NYHA class IV status as well as prior
use of LV pacing which was not very successful, the risks
outweighed the benefits. However, patient's pacemaker HR was
increased to 90 to improve forward flow. Patient approached new
dry weight of 110kg (came in at 121 kg). His K+ goal was kept
near 5-5.5 with aggressive supplementation. On discharge,
patient told to stop his lasix (160 mg [**Hospital1 **]) and carvedilol (25
mg [**Hospital1 **]). Instead, he will take torsemide (80 mg [**Hospital1 **]) and
metoprolol succinate (50 mg daily in AM). He was also discharged
on potassium supplements 40 meq tid. Patient was informed to
check his weights on a daily basis, nutrition care was discussed
with patient as well. If the patient were to gain weight (i.e.
[**1-26**] lbs), he was to take metolazone 5 mg tablet and call [**Hospital 1902**]
clinic. He had f/u planned with [**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:  s/p MI in [**2153**]
-CABG:  CABG in [**2154**] (LIMA-LAD, SVG-D1/D3, SVG-OM3), redo CABG
[**2177-4-8**] (SVG-RCA, SVG-SVG-OM3)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:  VT s/p BiV-ICD placement [**2172**]
3. OTHER PAST MEDICAL HISTORY:
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic

MEDICATION ON ADMISSION: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: T=35.9 BP=77/59 HR=90 RR=12 O2 sat=95%
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.

SOCIAL HISTORY: Tobacco history: quit 30 yrs ago, 1 ppd x 20 yrs
-ETOH:  rare use
-Illicit drugs: denies
He is trained as an attorney but works in purchasing companies,
predominantly telecommunications and sports teams. Married. Has
2 adopted boys, aged 18 and 20.
Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Other primary cardiomyopathies,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Automatic implantable cardiac defibrillator in situ,Heart valve replaced by transplant,Diseases of tricuspid valve,Other sequelae of chronic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hyperparathyroidism, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heparin-induced thrombocytopenia (HIT),Acute upper respiratory infections of unspecified site,Anemia in chronic kidney disease,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anxiety state, unspecified,Obesity, unspecified,Dyspepsia and other specified disorders of function of stomach,Personal history of tobacco use,Encounter for palliative care
Ac on chr syst hrt fail,Ac kidny fail, tubr necr,Prim cardiomyopathy NEC,Acidosis,Hyp kid NOS w cr kid V,End stage renal disease,Status autm crd dfbrltr,Heart valve transplant,Tricuspid valve disease,Oth sequela, chr liv dis,DMII wo cmp nt st uncntr,Long-term use of insulin,Hyperparathyroidism NOS,Hypothyroidism NOS,Pure hypercholesterolem,Obstructive sleep apnea,Heparin-indu thrombocyto,Acute uri NOS,Anemia in chr kidney dis,Cardiac dysrhythmias NEC,BPH w/o urinary obs/LUTS,Anxiety state NOS,Obesity NOS,Stomach function dis NEC,History of tobacco use,Encountr palliative care
Admission Date:  [**2179-8-29**]              Discharge Date:   [**2179-9-12**]

Date of Birth:  [**2111-6-10**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Heparin Agents

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Acute exacerbation of CHF

Major Surgical or Invasive Procedure:
- cardiac catheterization [**2179-9-1**]
- central line placement
- [**Month/Day/Year 106792**] placement [**2179-9-10**]


History of Present Illness:
68 year old man with CAD s/p CABG [**2154**] (LIMA-LAD, SVG-D1/D3,
SVG-OM3), followed by repeat CABG [**2176**] in setting of MVR for
severe MR (SVG-RCA, SVG-SVG-OM3), CHF with EF 10%, VT s/p
BiV-ICD placement [**2172**], HIT, OSA, HTN, and DM, recently admitted
[**Date range (3) 106793**] and again [**Date range (3) 106794**] with acute on chronic
CHF exacerbation for aggressive diuresis. He presented with
probable acute volume overload, hyperkalemia and azotemia and
was admitted to [**Hospital1 1516**] cardiology service. Patient had cardiac
catheterization today ([**2179-9-1**]) for assessment of worsening CHF
with focal wall motion abnormalities on most recent
echocardiogram. He was transferred to the CCU service for
management of CHF and worsening renal function, requiring
continuous [**Last Name (un) **]-venous dialysis (CVVD), not currently on
dialysis.
.
Mr. [**Known lastname **] [**Last Name (Titles) **] Dr. [**Last Name (STitle) **] yesterday because he has developed
dyspnea and has gained 5 lbs. He otherwise is feeling OK. He was
advised to take 5 mg metolazone and increase his torsemide to
100 mg [**Hospital1 **]. Labs were checked this morning and returned: Na 131,
K 6.2, Cl 95, C02 26, BUN 104, Creatinine 3.4. Dr. [**Last Name (STitle) **] called
Mr. [**Known lastname 106795**] wife with these results and asked that he come into
the hospital, for direct admission to [**Hospital Ward Name 121**] 3. Since leaving home
he has been becoming increasingly breathless. He is happy to be
coming back sooner rather than later, because he really would
like to avoid dialysis (as with the last admission).
.
On night of [**2179-8-30**] he had been waking up every twenty minutes or
so with a jolt that he think originates from his ICD. He is on
monitored telemetry and sent samples last night. He typically
does not become breathless while lying flat, however he
presently feels that his ditended abdomen is preventing him from
breathing well.
.
Immediate relevant past medical history includes two
exacerbations of heart failure with volume overload in [**Month (only) 216**]
this year. During his admission (d/c date [**2179-8-2**]) several
liters were diuresed but this was limited by advancing azotemia
and low blood pressure. Despite diuresis being minimal he claims
to have felt less bloated and less dyspneic.
.
He stated that he was doing well after discharge until
8/17-18/09 when he started gaining weight and suffering
increased dyspnea, both on exertion and at rest. His goal intake
was 1200 mg or less of sodium and fewer calories per day. He
continued to use his BiPAP mask at night. However, he reported
gaining 6 pounds over two days with an increase in abdominal
girth/firmness. His weight was 224 pounds with a dry weight on
discharge [**2179-8-2**] of 216 pounds. He was admitted and he was
estimated as [**10-7**] kg above his dry weight. He was admitted to
the CCU where he was continued on lasix bolus and gtt, along
with milrinone bolus and gtt. He was continued on metolazone 5
mg [**Hospital1 **]. CVVH was started via R femoral line and continued for
several days until it clotted off. Through this time, patient
was continued on low dose neosynephrine as needed to support
blood pressure with goal MAP of 55. When CVVH line clotted off
([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone
with good UOP of 100-200 cc/hr. Patient was net -15 L fluid
removal on discharge.
.
During that admission, EP was contact[**Name (NI) **] about the possibility of
LV pacing, as patient has severe LV/RV dysynchrony on echo. It
was felt that given his NYHA class IV status as well as prior
use of LV pacing which was not very successful, the risks
outweighed the benefits. However, patient's pacemaker HR was
increased to 90 to improve forward flow. Patient approached new
dry weight of 110kg (came in at 121 kg). His K+ goal was kept
near 5-5.5 with aggressive supplementation. On discharge,
patient told to stop his lasix (160 mg [**Hospital1 **]) and carvedilol (25
mg [**Hospital1 **]). Instead, he will take torsemide (80 mg [**Hospital1 **]) and
metoprolol succinate (50 mg daily in AM). He was also discharged
on potassium supplements 40 meq tid. Patient was informed to
check his weights on a daily basis, nutrition care was discussed
with patient as well. If the patient were to gain weight (i.e.
[**1-26**] lbs), he was to take metolazone 5 mg tablet and call [**Hospital 1902**]
clinic. He had f/u planned with [**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic.

.
Other problems during this last admission included acute renal
failure, hypokalemia, OSA, anxiety, diabetes, hypothyroidism, as
described below in past medical history.
.
He was a direct admit from home and thus not seen in the ED.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.


Past Medical History:
. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:  s/p MI in [**2153**]
-CABG:  CABG in [**2154**] (LIMA-LAD, SVG-D1/D3, SVG-OM3), redo CABG
[**2177-4-8**] (SVG-RCA, SVG-SVG-OM3)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:  VT s/p BiV-ICD placement [**2172**]
3. OTHER PAST MEDICAL HISTORY:
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic

tx
-single lead ICD was placed
-had 2-3 episodes of appropriate ICD firing -> new lead placed
[**2167**]
-continued to have shocks -> tried betapace w/o relief
-started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks
-had BiV ICD placed in [**2172**]
-attempted VT ablation in [**2174**] w/ reload of amiodarone
-last shocked:
-ICD last interrogated: [**2179-8-31**]
# S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine
valve) [**3-/2177**]
# 3+ TR
# HTN
# CKD - baseline mid 2's
# DM
-insulin dependent
# Hypothyroidism
# Hyperparathyroidism
# Hypercalcemia
# Osteopenia
# Hypercholesterolemia
# Dyspepsia
# Sleep apnea
# Obesity
# LFT abnormalities attributed to NASH, possibly amio
# HIT


Social History:
Tobacco history: quit 30 yrs ago, 1 ppd x 20 yrs
-ETOH:  rare use
-Illicit drugs: denies
He is trained as an attorney but works in purchasing companies,
predominantly telecommunications and sports teams. Married. Has
2 adopted boys, aged 18 and 20.


Family History:
Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.


Physical Exam:
VS: T=35.9 BP=77/59 HR=90 RR=12 O2 sat=95%
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with elevated JVP.
CARDIAC: RR (paced), normal S1, S2. No m/r/g. No thrills, lifts.
No S3 or S4. Distant heart sounds
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, mild
end-expiratory wheezes, no crackles or rhonchi.
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: cool b/l, No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+


Pertinent Results:
Labs on admission:
[**2179-8-29**] 02:50PM BLOOD WBC-9.2 RBC-4.78 Hgb-14.2 Hct-45.6 MCV-95
MCH-29.6 MCHC-31.0 RDW-16.3* Plt Ct-256
[**2179-8-29**] 02:50PM BLOOD PT-13.7* PTT-24.6 INR(PT)-1.2*
[**2179-8-29**] 02:50PM BLOOD Glucose-196* UreaN-107* Creat-3.9*#
Na-134 K-6.7* Cl-97 HCO3-23 AnGap-21*
[**2179-8-29**] 02:50PM BLOOD ALT-49* AST-47* LD(LDH)-340* CK(CPK)-55
AlkPhos-177* TotBili-0.6
[**2179-8-29**] 02:50PM BLOOD Albumin-4.0 Calcium-9.1 Phos-3.8 Mg-2.5
[**2179-9-11**] 04:21AM BLOOD WBC-26.6* RBC-3.39* Hgb-10.2* Hct-30.2*
MCV-89 MCH-29.9 MCHC-33.6 RDW-17.1* Plt Ct-184
[**2179-9-11**] 04:21AM BLOOD Neuts-83* Bands-4 Lymphs-2* Monos-8 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-1*
[**2179-9-11**] 05:56PM BLOOD PTT-71.6*
[**2179-9-11**] 04:21AM BLOOD PT-23.1* PTT-62.3* INR(PT)-2.2*
[**2179-9-11**] 04:21AM BLOOD Plt Smr-NORMAL Plt Ct-184
[**2179-9-11**] 04:21AM BLOOD Glucose-148* UreaN-44* Creat-5.2* Na-125*
K-5.1 Cl-91* HCO3-21* AnGap-18
[**2179-9-11**] 04:21AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3
[**2179-9-11**] 09:32AM BLOOD Type-MIX pH-7.36
[**2179-9-11**] 09:32AM BLOOD Lactate-1.6
.
2D-ECHOCARDIOGRAM [**2179-8-31**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. Left ventricular systolic function is severely
depressed with thinned and akinetic anterior,septal,and apical
segments with severe hypokinesis elsewhere. The right
ventricular cavity is dilated with borderline normal free wall
function. [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. There
is no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. The
motion of the mitral valve prosthetic leaflets appears normal.
The transmitral gradient is normal for this prosthesis. No
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Severe [4+] tricuspid regurgitation is seen.
Significant pulmonic regurgitation is seen. There is a
trivial/physiologic pericardial effusion. Although the tricuspid
regurgitation gradient is approximately 18 mmHg there is
probably significant pulmonary artery systolic hypertension
(since right atrial pressure is likely elevated in the setting
of severe tricuspid regurgitaiton).
Compared with the prior study (images reviewed) of [**2179-7-30**],
findings are similar. The pulmonary artery systolic pressure was
probably elevated in the prior study as well.
.
CARDIAC CATH [**2179-9-1**]:
COMMENTS:
1. Coronary angiography in this right dominant system revealed
severe
multivessel coronary artery disease.  The native LAD and LCX
were known to be occluded, and therefore the native left
coronary artery was not engaged.  The RCA had a 50% stenosis in
the mid-portion.
2. Selective vein graft angiography of the saphenous vein grafts
revealed a patent graft to the RCA.  The SVG to D1 graft was
patent,
with slow flow to the D3 from this graft that was similar in
appearance to previous cath from [**2176**].  The SVG to OM3 graft was
patent.  The new interposition graft from CABG in [**2176**] to
SVG-OM3 was not seen.
3. Selective arterial graft angiography of the LIMA to LAD was
not
performed.
4. Resting hemodynamics revealed markedly elevated right sided
filling pressures with mean RA pressure of 30 mmHg.  The
severely increased RA pressure was associated with a moderate
increase in pulmonary pressures, which suggests tricuspid
regurgitation.  The left sided filling pressures were also
increased with mean PCW pressure of 30 mmHg and LVEDP of 33
mmHg.  There was no evidence of aortic stenosis.  The cardiac
output as calculated by Fick equation was moderately depressed
at 3.4 L/min.
FINAL DIAGNOSIS:
1. Severe coronary artery disease.
2. Elevated left and right sided filling pressures.
3. Likely severe tricuspid regurgitation.
4. Depressed cardiac output.
.
TTE [**2179-9-10**]:
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= [**10-12**]
%). The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
A bioprosthetic mitral valve prosthesis is present. The
gradients are higher than expected for this type of prosthesis.
There is no pericardial effusion.
The inlet area of the [**Month/Year (2) 106792**] 2.5 device was located 5.o cm away
from the aortic valve. The device was then pulled back 1 cm so
that the inlet area was properly located at 4.0 cm from the
aortic valve.
Compared with the findings of the prior study (images reviewed)
of [**2179-8-31**], the left ventricular end diastolic
dimension is reduced (7.9 cm previously, and 6.5 cm now). The
left ventricular total stroke volume (ventricular stroke volume
plus [**Year (4 digits) 106792**]-driven flow; as determined by the mitral inflow
Doppler velocity time integral) is approximately 50% higher (VTI
pre-[**Year (4 digits) 106792**] was 45 cm vs current VTI 65).
.
CHEST XRAY [**2179-9-11**]:
FINDINGS: There has been interval placement of an [**Month/Day/Year 106792**]
percutaneous
ventricular assist device, the catheter coursing within the
abdominal and
thoracic aorta with the distal tip located near the expected
aortic valve
plane. Additionally, a Swan-Ganz catheter has been placed with
the distal tip terminating in the left pulmonary artery.
However, as discussed by phone with Dr. [**Name (STitle) 26842**], a portion of
the catheter overlying the thoracic spine is not well
visualized, and a repeat chest radiograph is recommended of this
region and to exclude the possibility of catheter fracture.
Cardiac silhouette remains grossly enlarged. New poorly defined
opacity has developed in the right upper lobe. Linear
atelectasis left base.
IMPRESSION: New right upper lobe opacity, which could reflect
acute
aspiration, developing infectious pneumonia, or, in the setting
of mitral
regurgitation, asymmetric edema.
.
CHEST XRAY [**2179-9-11**]:
The Swan-Ganz catheter is now visualized continuously, and
continues to
terminate in the region of the left pulmonary artery. The
[**Month/Day/Year 106792**]
percutaneous ventricular assist device is more fully visualized
on the current study, with its distal tip projecting in the
region of the left ventricle.  Cardiac silhouette remains
markedly enlarged.
IMPRESSION: Subtle opacity in right upper lobe has nearly
resolved. Minimal linear atelectasis persists in the left base.
.


Brief Hospital Course:
68 yo M with severe end-stage NYHA class IV systolic CHF with EF
of 20%, secondary to ischemic cardiomyopathy, admitted [**2179-8-31**]
for acute exacerbation of CHF and transferred to CCU from [**Hospital1 1516**]
service for aggressive diuresis and acute on chronic renal
failure secondary to worsening CHF.
.
The patient presented in end-stage systolic CHF with an LVEF
20%, severely akinetic left ventricle. The patient was
agressively diuresed with lasix gtt and metolazone.
Additionally, he underwent CVVH for about 5 days with the goal
of removing several liters of fluid.  After CVVH, patient was
diuresed with Bumex and Metolazone with minimal effect. Since
the patient was anuric-oliguric despite aggressive diuresis,
ultrafiltration was also performed several times for fluid
removal. Additionally, the patient was hypotensive and
maintained on several pressor medications including milrinone,
dobutamine and vasopressin.  Despite several pressors and
aggressive fluid removal measures, he continued to have poor
end-organ perfusion to kidneys and remained oliguric. The
patient's poor prognosis and deteriorating hemodynamic status
was discussed with patient and his wife, it was decided to
implant [**Name (NI) 106792**] catheter-based ventricular assist device as a
final intervention.  The goal of this intervention was to
improve cardiac output and see if improved perfusion to kidneys
would allow for improved renal function.  If the [**Name (NI) 106792**] were to
show improved renal function, then the patient would be
considered a candidate for an LVAD as a destination therapy.
The [**Name (NI) 106792**] device was placed on [**2179-9-10**], but failed to improve
his cardiac index or renal perfusion significantly.
Consequently, it was felt that further interventions would be
unsuccessful and the his code status was changed to DNR/DNI and
"comfort measures only" after extensive discussion with the
patient and his family.  A magnet was placed over the patient's
pacemaker, pressors were withdrawn and the patient expired on
the morning of [**2179-9-12**].


Medications on Admission:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap

PO DAILY (Daily).
14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as
medication.
Disp:*30 Tablet(s)* Refills:*0*
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
19. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: 45 units at breakfast, 50 units at dinner units
Subcutaneous once a day.
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 25
units at bedtime units Subcutaneous once a day.
21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO three times a
day: please take 40 meq potassium supplements three times a day.

22. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day.
Disp:*240 Tablet(s)* Refills:*2*


Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
N/A

Followup Instructions:
N/A
{'Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Other primary cardiomyopathies,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Automatic implantable cardiac defibrillator in situ,Heart valve replaced by transplant,Diseases of tricuspid valve,Other sequelae of chronic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hyperparathyroidism, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heparin-induced thrombocytopenia (HIT),Acute upper respiratory infections of unspecified site,Anemia in chronic kidney disease,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anxiety state, unspecified,Obesity, unspecified,Dyspepsia and other specified disorders of function of stomach,Personal history of tobacco use,Encounter for palliative care'}


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: Acute exacerbation of CHF

PRESENT ILLNESS: 68 year old man with CAD s/p CABG [**2154**] (LIMA-LAD, SVG-D1/D3,
SVG-OM3), followed by repeat CABG [**2176**] in setting of MVR for
severe MR (SVG-RCA, SVG-SVG-OM3), CHF with EF 10%, VT s/p
BiV-ICD placement [**2172**], HIT, OSA, HTN, and DM, recently admitted
[**Date range (3) 106793**] and again [**Date range (3) 106794**] with acute on chronic
CHF exacerbation for aggressive diuresis. He presented with
probable acute volume overload, hyperkalemia and azotemia and
was admitted to [**Hospital1 1516**] cardiology service. Patient had cardiac
catheterization today ([**2179-9-1**]) for assessment of worsening CHF
with focal wall motion abnormalities on most recent
echocardiogram. He was transferred to the CCU service for
management of CHF and worsening renal function, requiring
continuous [**Last Name (un) **]-venous dialysis (CVVD), not currently on
dialysis.
.
Mr. [**Known lastname **] [**Last Name (Titles) **] Dr. [**Last Name (STitle) **] yesterday because he has developed
dyspnea and has gained 5 lbs. He otherwise is feeling OK. He was
advised to take 5 mg metolazone and increase his torsemide to
100 mg [**Hospital1 **]. Labs were checked this morning and returned: Na 131,
K 6.2, Cl 95, C02 26, BUN 104, Creatinine 3.4. Dr. [**Last Name (STitle) **] called
Mr. [**Known lastname 106795**] wife with these results and asked that he come into
the hospital, for direct admission to [**Hospital Ward Name 121**] 3. Since leaving home
he has been becoming increasingly breathless. He is happy to be
coming back sooner rather than later, because he really would
like to avoid dialysis (as with the last admission).
.
On night of [**2179-8-30**] he had been waking up every twenty minutes or
so with a jolt that he think originates from his ICD. He is on
monitored telemetry and sent samples last night. He typically
does not become breathless while lying flat, however he
presently feels that his ditended abdomen is preventing him from
breathing well.
.
Immediate relevant past medical history includes two
exacerbations of heart failure with volume overload in [**Month (only) 216**]
this year. During his admission (d/c date [**2179-8-2**]) several
liters were diuresed but this was limited by advancing azotemia
and low blood pressure. Despite diuresis being minimal he claims
to have felt less bloated and less dyspneic.
.
He stated that he was doing well after discharge until
8/17-18/09 when he started gaining weight and suffering
increased dyspnea, both on exertion and at rest. His goal intake
was 1200 mg or less of sodium and fewer calories per day. He
continued to use his BiPAP mask at night. However, he reported
gaining 6 pounds over two days with an increase in abdominal
girth/firmness. His weight was 224 pounds with a dry weight on
discharge [**2179-8-2**] of 216 pounds. He was admitted and he was
estimated as [**10-7**] kg above his dry weight. He was admitted to
the CCU where he was continued on lasix bolus and gtt, along
with milrinone bolus and gtt. He was continued on metolazone 5
mg [**Hospital1 **]. CVVH was started via R femoral line and continued for
several days until it clotted off. Through this time, patient
was continued on low dose neosynephrine as needed to support
blood pressure with goal MAP of 55. When CVVH line clotted off
([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone
with good UOP of 100-200 cc/hr. Patient was net -15 L fluid
removal on discharge.
.
During that admission, EP was contact[**Name (NI) **] about the possibility of
LV pacing, as patient has severe LV/RV dysynchrony on echo. It
was felt that given his NYHA class IV status as well as prior
use of LV pacing which was not very successful, the risks
outweighed the benefits. However, patient's pacemaker HR was
increased to 90 to improve forward flow. Patient approached new
dry weight of 110kg (came in at 121 kg). His K+ goal was kept
near 5-5.5 with aggressive supplementation. On discharge,
patient told to stop his lasix (160 mg [**Hospital1 **]) and carvedilol (25
mg [**Hospital1 **]). Instead, he will take torsemide (80 mg [**Hospital1 **]) and
metoprolol succinate (50 mg daily in AM). He was also discharged
on potassium supplements 40 meq tid. Patient was informed to
check his weights on a daily basis, nutrition care was discussed
with patient as well. If the patient were to gain weight (i.e.
[**1-26**] lbs), he was to take metolazone 5 mg tablet and call [**Hospital 1902**]
clinic. He had f/u planned with [**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:  s/p MI in [**2153**]
-CABG:  CABG in [**2154**] (LIMA-LAD, SVG-D1/D3, SVG-OM3), redo CABG
[**2177-4-8**] (SVG-RCA, SVG-SVG-OM3)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:  VT s/p BiV-ICD placement [**2172**]
3. OTHER PAST MEDICAL HISTORY:
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic

MEDICATION ON ADMISSION: 1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: T=35.9 BP=77/59 HR=90 RR=12 O2 sat=95%
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.

SOCIAL HISTORY: Tobacco history: quit 30 yrs ago, 1 ppd x 20 yrs
-ETOH:  rare use
-Illicit drugs: denies
He is trained as an attorney but works in purchasing companies,
predominantly telecommunications and sports teams. Married. Has
2 adopted boys, aged 18 and 20. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Other primary cardiomyopathies,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Automatic implantable cardiac defibrillator in situ,Heart valve replaced by transplant,Diseases of tricuspid valve,Other sequelae of chronic liver disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hyperparathyroidism, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heparin-induced thrombocytopenia (HIT),Acute upper respiratory infections of unspecified site,Anemia in chronic kidney disease,Other specified cardiac dysrhythmias,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Anxiety state, unspecified,Obesity, unspecified,Dyspepsia and other specified disorders of function of stomach,Personal history of tobacco use,Encounter for palliative care'}
