CHIEF COMPLAINT: Cardiac arrest

PRESENT ILLNESS: The patient is a 76 year old male with a history of CAD s/p
CABG, HTN, AF, syncope s/p PPM who presents following
out-of-hospital cardiac arrest. The patient has been noted to be
slightly dysnpic over the last two days. He has not experienceid
any chest pain, palpitations, light-headnedness, or any other
symtpoms. On the day of presenation, the patient went out to do
errands. He had spoken to his wife pulling into a wall-mart
parking lot, and did not make any notable complaints. He was
found down in the parking lot unresponsive. The event was
unwitnessed. Security was called, who placed an AED on the
patient, and fired twice for a shockable rhythm. EMS was
activated. From being found down to confirmation of a purfusing
rhythm, the estimated time down is roughly ten minutes.
He was intubated in the field and transfered to [**Hospital3 6592**].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2182**] by Dr. [**Last Name (STitle) 4026**]
[**Name (STitle) 41709**] CORONARY INTERVENTIONS:
-PACING/ICD: PPM placed in [**2189**] following syncopal event
3. OTHER PAST MEDICAL HISTORY:
.
Atrial Fibrillation

MEDICATION ON ADMISSION: Warfarin 2mg daily
Lisinorpil 20mg daily
Zocor 10mg daily
HCTZ 25mg daily
Fishoil 1000mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=96 BP= 123/71 HR= 60 RR= 16 O2 sat= 100% AC TV 600/5/40%
GENERAL: Elderly male, intubated, sedated, unresponsive. In
C-colllar.
HEENT: NCAT. PERRL (3mm to 2mm), in C-collar.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Scar on left leg and
arm.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Neuro: Absenct corneal reflex, down going babinski, no clonus,
opens eyes to name calling

FAMILY HISTORY: 

SOCIAL HISTORY: Married, former
Ventricular fibrillation,Septicemia due to pseudomonas,Pneumonia due to other gram-negative bacteria,Ventilator associated pneumonia,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Acute on chronic combined systolic and diastolic heart failure,Septic shock,Toxic encephalopathy,Severe sepsis,Mixed acid-base balance disorder,Aneurysm of heart (wall),Other and unspecified infection due to central venous catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac pacemaker in situ,Pressure ulcer, stage II,Other abnormal glucose,Anemia, unspecified,Aortocoronary bypass status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Ventricular fibrillation,Pseudomonas septicemia,Pneumo oth grm-neg bact,Ventltr assoc pneumonia,Acute respiratry failure,Ac kidny fail, tubr necr,Anoxic brain damage,Ac/chr syst/dia hrt fail,Septic shock,Toxic encephalopathy,Severe sepsis,Mixed acid-base bal dis,Aneurysm of heart,Oth/uns inf-cen ven cath,Hypertension NOS,Hyperlipidemia NEC/NOS,Status cardiac pacemaker,Pressure ulcer, stage II,Abnormal glucose NEC,Anemia NOS,Aortocoronary bypass,Abn react-artif implant
Admission Date:  [**2194-11-28**]              Discharge Date:   [**2194-12-12**]

Date of Birth:  [**2118-2-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Cardiac arrest

Major Surgical or Invasive Procedure:
Cardioversion
Intubation


History of Present Illness:
The patient is a 76 year old male with a history of CAD s/p
CABG, HTN, AF, syncope s/p PPM who presents following
out-of-hospital cardiac arrest. The patient has been noted to be
slightly dysnpic over the last two days. He has not experienceid
any chest pain, palpitations, light-headnedness, or any other
symtpoms. On the day of presenation, the patient went out to do
errands. He had spoken to his wife pulling into a wall-mart
parking lot, and did not make any notable complaints. He was
found down in the parking lot unresponsive. The event was
unwitnessed. Security was called, who placed an AED on the
patient, and fired twice for a shockable rhythm. EMS was
activated. From being found down to confirmation of a purfusing
rhythm, the estimated time down is roughly ten minutes.
He was intubated in the field and transfered to [**Hospital3 6592**].

.
While there, the patient was noted to be hemodynapically stable.
A CT scan of the head and neck were performed, and reportadly
normal. The patients wife says that at [**Name (NI) **] the patient was
squeezing hands on command and was intially grabing at lines
with purposeful movement of all for extremities. He was
emergently transfered to [**Hospital1 18**] for futher evaluation and care.
.
In the ED, the patient's HR was 72, BP 137/74, satting 100% on
the ventillator. He was give IV versed for sedation. He was
noted to have BRB in the anal vault. The patient was transfered
to the CCU for further care.
.
On review of systems, 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. He denies recent fevers, chills or rigors.
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,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, or presyncope


Past Medical History:
1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2182**] by Dr. [**Last Name (STitle) 4026**]
[**Name (STitle) 41709**] CORONARY INTERVENTIONS:
-PACING/ICD: PPM placed in [**2189**] following syncopal event
3. OTHER PAST MEDICAL HISTORY:
.
Atrial Fibrillation


Social History:
Married, former

Physical Exam:
VS: T=96 BP= 123/71 HR= 60 RR= 16 O2 sat= 100% AC TV 600/5/40%
GENERAL: Elderly male, intubated, sedated, unresponsive. In
C-colllar.
HEENT: NCAT. PERRL (3mm to 2mm), in C-collar.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Scar on left leg and
arm.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Neuro: Absenct corneal reflex, down going babinski, no clonus,
opens eyes to name calling


Pertinent Results:
Labs on admission:
.
[**2194-11-28**] 09:00PM BLOOD WBC-17.6* RBC-3.38* Hgb-12.4* Hct-34.7*
MCV-103* MCH-36.8* MCHC-35.7* RDW-16.3* Plt Ct-152
[**2194-11-29**] 01:54AM BLOOD WBC-13.4* RBC-3.44* Hgb-12.2* Hct-34.5*
MCV-100* MCH-35.4* MCHC-35.3* RDW-16.9* Plt Ct-148*
[**2194-11-28**] 09:00PM BLOOD Neuts-83.5* Lymphs-12.1* Monos-3.5
Eos-0.3 Baso-0.5
.
[**2194-11-28**] 09:00PM BLOOD PT-28.2* PTT-33.0 INR(PT)-2.8*
.
[**2194-11-28**] 09:00PM BLOOD Glucose-161* UreaN-28* Creat-1.3* Na-139
K-4.7 Cl-105 HCO3-20* AnGap-19
[**2194-11-29**] 01:54AM BLOOD Glucose-187* UreaN-28* Creat-1.1 Na-135
K-5.2* Cl-105 HCO3-19* AnGap-16
.
[**2194-11-28**] 09:00PM BLOOD ALT-20 AST-27 CK(CPK)-83 AlkPhos-60
TotBili-0.8
.
[**2194-11-29**] 01:54AM BLOOD CK(CPK)-124
[**2194-11-29**] 11:38AM BLOOD CK(CPK)-269*
[**2194-11-28**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.27*
[**2194-11-29**] 01:54AM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-0.34*
[**2194-11-29**] 11:38AM BLOOD CK-MB-14* MB Indx-5.2 cTropnT-0.17*
.
[**2194-11-28**] 09:00PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.3
[**2194-11-29**] 01:54AM BLOOD Triglyc-113 HDL-30 CHOL/HD-3.4 LDLcalc-49
.
[**2194-11-28**] 09:16PM BLOOD Type-[**Last Name (un) **] Temp-37.3 pH-7.26*
[**2194-11-28**] 11:11PM BLOOD Type-ART Rates-/16 Tidal V-600 PEEP-5
FiO2-100 pO2-408* pCO2-34* pH-7.39 calTCO2-21 Base XS--3
AADO2-278 REQ O2-53 -ASSIST/CON Intubat-INTUBATED
[**2194-11-28**] 09:16PM BLOOD Glucose-152* Lactate-4.2* Na-141 K-4.8
Cl-102 calHCO3-21
.
Urine studies:
.
[**2194-11-28**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2194-11-28**] 09:00PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2194-11-28**] 09:00PM URINE RBC-[**11-6**]* WBC-0-2 Bacteri-MOD Yeast-NONE
Epi-0-2
[**2194-11-28**] 09:00PM URINE CastGr-0-2 CastHy-[**2-19**]*
.
Studies/Imaging:
.
CXR [**11-28**] -
FINDINGS: Single AP chest radiograph without comparison shows ET
tube
terminating 3.6 cm above the carina. The lungs are clear. The
heart is
moderately enlarged. The patient is status post median
sternotomy and CABG.
There is no pleural effusion or pneumothorax. NG-tube is in
satisfactory
position with tip in the stomach. Leads of a right-sided
pacemaker terminate
in the right atrium and ventricle. Surgical staple overlies the
left upper
abdomen.

IMPRESSION: Moderate cardiomegaly without evidence of pneumonia
or overt CHF.
.
CTA [**11-28**] -
IMPRESSION:

1. No pulmonary embolism or thoracic aortic dissection.

2. Small-to-moderate bibasilar consolidation with aspiration
favored over
pneumonia.

3. Small amount of secretions surrounding the proximally
visualized
endotracheal tube.

4. Dilated ascending thoracic aorta
.
ECHO [**11-28**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with inferior, inferolateral and basal inferoseptal
akinesis (likely RCA territory). There is moerate to severe
hypokinesis of the remaining segments (LVEF = 15-20%). The right
ventricular cavity is mildly dilated with borderline normal free
wall function. The aortic root is moderately dilated at the
sinus level. The ascending aorta is moderately dilated. The
descending thoracic aorta is mildly dilated. There are three
moderately thickened aortic leaflets, with poor excursion.
Two-dimensional imaging suggests significant aortic stenosis,
but its severity cannot be reliably quantified given low LV
stroke volume. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.

IMPRESSION: Severe regional and global left ventricular systolic
dysfunction, suggestive of a global process (toxic, metabolic,
etc.) on a background of prior inferior myocardial infarction.
Mild right ventricular systolic dysfunction. Significant aortic
stenosis. Moderate tricuspid regurgitation. Mild pulmonary
hypertension. Dilated thoracic aorta.
.
ECHO [**12-8**]:
.
The left atrium is dilated. There is an inferobasal left
ventricular aneurysm. There is severe regional left ventricular
systolic dysfunction with akinesis of the inferior,
inferolateral segments. The other segments are moderately
hypokinetic. There is no left ventricular outflow obstruction at
rest or with Valsalva. The right ventricular cavity is mildly
dilated with borderline normal free wall function. The aortic
root is moderately dilated at the sinus level. The ascending
aorta is moderately dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. Significant aortic stenosis is present (not
quantified as LV systolic function is significantly impaired).
The mitral valve leaflets are mildly thickened. Mild mitral
regurgitation is seen. Moderate tricuspid regurgitation is seen.
The tricuspid regurgitation jet is eccentric and may be
underestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2194-11-29**],
the inferior and inferolateral akinesis persists. The other
segments have slightly better function. The other findings -
aortic stenosis, mild mitral and at least moderate tricuspid
regurgitation - are similar.

Brief Hospital Course:
76 y/o male w/ a hx of CAD s/p CABG, syncope s/p PPM, AF who
presented with cardiac arrest, intubated and transferred to
[**Hospital1 18**] for further care.
.
# SEPSIS.  Sources included VAP and line related infection.  On
[**11-30**], pt was found to be febrile with SBPs below 90mmHg, and RR
20-30s.  BCx from R femoral line placed on [**12-1**] (no neck access
due to neck collar) grew Pseudomonas A.  He remained hypotensive
and required pressor support with Dopamine and Levophed.
Patient also had also developed bilateral opacities on CXR,
thick and bloody secretions.  His sputum [**12-1**] and [**12-2**] grew
MSSA and Enterobactericae.  UA and UCx were negative, there was
no diarrhea.  R femoral line was removed on [**12-3**].  He was
started on Zosyn and Vancomycin on [**12-1**] and pt intially
defervesced on this regimen, however next day became febrile
again.  Tobramycin was added for initially unknown GNR coverage
in sputum.  Once Cx from sputum and perphery were finalized, ABx
regimen was changed to nafcicillin IV and ciprofloxacin for a
total treatment length of 14 days.  His dopamine was weaned on
[**12-2**], while levophed was weaned on [**12-6**].  Pt. was successfully
extubated on [**12-6**]. He remained afebrile until discharge.  Since
patient developed worsening renal failure on [**12-8**], which was
felt to be consistent w/ AIN, his nafcillin was changed to
cefazolin IV.   He has completed that course.  He is still due
to complete the 14 day course of cipro, and is currently on day
10 of 14.
.
# RESPIRATORY FAILURE.  Pt. was intubated on transfer.  Most
likely felt to be [**1-18**] possible volume overload and VAP (see
above).  He was initially afebrile and euvolemi on exam, but
required volume resuscitation due to hypotension developed on
HD#2. Initial CXRs did not show vascular congestion or
consolidation, however pt became febrile on [**11-30**] and was found
to have b/l lower lobe opacities.  He was started on treatment
for VAP.  ABGs were consistent w/ mixed respiratory alkalosis
and metabolic alkalosis, likely [**1-18**] sepsis and possible CNS
injury. PaO2/FiO2 min was 214.  By [**12-6**] pH and CO2 normlaized,
CNS status improved significantly and patient was successfully
extubated. Pt. continued to have mild wheezing on exam, treated
w/ albuterol nebs prn.  He has since been oxygenating well on
room air, and has not required additional nebulizer treatments.
.
# CORONARIES: Patient with history of CAD, s/p CABG. No ischemic
changes on EKG, although limited to interpret with V pacing. CKs
peaked at 269, MB at 15 w/ index 8.9 and normalized by HD#1.  It
was felt that CK elevations were due to fall and possible VF
that lead to cardiac arrest.  This event was not believed to be
ischemic in nature.  Patient was continued on ASA, beta-blocker
and ACE were held due to septic shock.  LDL was 49 and HbA1C was
6.2.  Patient was continued on simvastatin.  Low dose metoprolol
was restarted on [**12-7**] once BP tolerated.  Lisinopril was held
due to worsening RF, but has since been restarted.
.
# PUMP.  Patient w/ known history of CHF, systolic likely [**1-18**]
CAD.  Last EF of 30-35% on ECHO as outpatient in [**2194-6-17**].
Patient was noted to have EF of 15-20%, severe regional and
global left ventricular systolic dysfunction on a background of
prior inferior myocardial infarction  (akinesis). Mild right
ventricular systolic dysfunction was also noted.  Pt had
significant AS, moderate TR and mild PAH.  As patient was volume
resuscitated for septick shock, he became volume overloaded
evident w/ peripheral edema and vascular congestion on CXR.  As
sepsis was controlled and patient was extubated, he was started
on low dose lasix with moderate effect.  On [**12-7**] patient was
started on Spironolactone 25mg QD which was subsequently d/ced
due to worsening renal failure.  A repeat ECHO on [**12-8**] showed
mild improvement in EF 20-25%, new L inferobasal aneurysm, and
inferior and infrelolateral akinesis persisting w/ prior
findings.
  Given akinesis of inferior wall and atrial fibrillation,
patient was started on heparin gtt and transitioned to coumadin.
 Patient will require follow up ECHO and cardiology appt in one
month to assess for ICD placment.  He will have his repeat TTE
in [**1-19**] weeks, and see Dr. [**Last Name (STitle) **] in clinic for evaluation of
possible CRT/d.
.
# RHYTHM:  Hx of chronic Afib.  PPM interrogations showed
episodes of VT, followed VF prior to cardiac arrest.  Patient
received 2 shocks from AED. Throughout hospitalization patient
was in atrial fibrillation w/ v-pacing 40 - 60% of the time.  He
was restarted on coumadin as well as started on amiodarone 400mg
[**Hospital1 **] for cardioversion on [**12-8**] to augment CO w/ atrial kick.
Cardioversion with biphasic 200J and 300J was attempted with
patient remaining in atrial fibrillation.  The patient is being
continued at amioderone 400mg daily, and will have a second
attempt at cardioversion in [**1-19**] weeks.  He will also see Dr.
[**Last Name (STitle) **] in clinic in [**2-18**] weeks for ICD placement versus CRT/d.
.
# CARDIAC ARREST.   Based on records, it appears he was in VF
for up to 6 minutes and it is unclear how long patient remained
w/o rhythm.  During this time, he received two DCCV but it is
not entirely clear if he was receiving chest compressions as
well.  He was intubated in the field.  Pt was unresponsive on
admission.  No initial neurological exam off sedation was
performed at OSH.  In [**Name (NI) **] pt had "absent corneal reflexes but
opened eyes to name."  CT head at OSH was wnl.  Patient
underwent 24 hours of cooling to 34C per Artic sun cooling
protocol.  Repeat at [**Hospital1 18**] did not show ICH or infarction.  Exam
at 72h off sedation showed eyes opening to command, intact
corneal and pupillary reflexes, spontaneous extermities
movements and flexor withdrawal to pain, all consistent w/ ~ 50%
meaningful neurological recovery.  Neurology team was consulted
and followed patient throughout the stay.  On [**12-6**] patient was
following simple commands, responding to yes/no questions with
improving strength in all extremities.  He was extubated on
[**12-6**].  His neurological status improved, orientation (A&Ox3).
Patient with generalized weakness, but no focal deficit.  Given
previous cardiac arrest and EF ~ 20-25% patient is to undergo a
1mo follow up ECHO with further evaluation for ICD placement
with Dr. [**Last Name (STitle) **].
.
# HTN.  Patient was hypotensive in shock during early stages of
hospitalization.  Once shock resolved, patient was restarted on
low dose BBk, ACE, and spironolactone.
.
# BG management. Pt initially w/ FS consistently > 200.  No
known history of diabetes, w/ HbA1C of 6.2.  He was maintained
on TF while intubated.  His BG was consistently elevated and he
was on Lantus and ISS.  His lantus had to be uptitrated to
18units daily.  This regimen will be continued while in rehab,
but should be switched to metformin in coordination with his
PCP, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 41710**].
.
# ANEMIA.  Normocytic, hypoproliferative. HCT on admission of
35, dropping to 22.  HCT on discharge was 25.  This was felt to
be due to combination of ACD and dilutional effects from fluid
administaration (at HCT nadir, pt was 7.8L positive).  Fe
studies were consistent w/ ACD.  Haptoglobin was nl, as were
TSH, B12 and Folate. The patient was started on iron, folate,
and pyridoxime supplementation.
.
# RENAL FAILURE.  Baseline unknown.  Cr. on admission was 1.3
and fluctuated between 1.4 and 0.8 during cooling and sepsis.
On [**12-7**] Cr increased to 1.6 with diuresis and aldactone and
rose to maximum of 2.1.  This was felt to be most likely [**1-18**]
pre-renal etiology and AIN given FEUrea of 37% and WBC
cast/eosinophilia on UA.  Patient's nafcillin was switched to
cefazolin on [**12-8**].  At time of discharge, Cr was improved to
1.5.


Medications on Admission:
Warfarin 2mg daily
Lisinorpil 20mg daily
Zocor 10mg daily
HCTZ 25mg daily
Fishoil 1000mg TID


Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
Subcutaneous at bedtime.
14. Insulin Lispro 100 unit/mL Solution Sig: Sliding Scale
Subcutaneous qACHS: see attached sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Primary: Cardiac arrest, sepsis, pneumonia, acute renal failure
Secondary: coronary artery disease, heart failure, hypertension,
hyperlipidemia, chronic atrial fibrillation


Discharge Condition:
Hemodynamically stable, afebrile.


Discharge Instructions:
You were admitted to [**Hospital1 18**] with cardiac arrest.  To help treat
this event, you required intubation and a cooling procedure to
maintain your brain function.  Your course was complicated by
sepsis (severe infection in your blood and other orgains).  You
required treatment with multiple intravenous antibiotics and
medications to maintain your blood pressure.

With these treatments your condition improved significantly.
You were extubated and your mental functioning improved
significantly.

Your course was also complicated by worsening heart failurek,
kidney failure and atrial fibrillation (irregular heart rate in
your atrium).  You underwent a cardioversion procedure for
atrial fibrillation which was unsuccessful.  Your heart failure
and your kidney failure are much improved at time of discharge.
You will need to complete a 14 day course of ciprofloxacin to
treat your blood infection.  You are being discharged to rehab.
We will plan a second attempt at cardioversion in [**1-19**] weeks, and
you will see Dr. [**Last Name (STitle) **] in clinic for evaluation of an ICD in
[**2-18**] weeks.

Your medication regimen was also changed significantly from the
medications you were taking at home.  Please review the list
provided below and take the medications as prescribed.

It was felt that your cardiac arrest was likely due to a
dangerous arrhythmia, vetricular fibrillation (irregular heart
beat of your ventricle).  For this reason, you will require a
close follow up with your cardiologist and an additional
evaluation for a defibrillator, once your heart failure is
stable.

Should you experience worsening shortness of breath, chest pain,
sweats, palpitations, cough, fevers, chills, nausea, or any
other symptom concerning to you, please call the rehabilitation
facility doctor or go to the nearest emergency room.

Please follow up with your appointments as listed below.

Followup Instructions:
Please follow up with your PCP, [**Name10 (NameIs) **] and Neurologist.

You have a follow up with Dr. [**Last Name (STitle) **] on [**2193-12-28**] at 1:20pm in
the [**Location (un) 8661**] Building of the [**Hospital Ward Name 516**] of [**Hospital1 18**] on the [**Location (un) 3971**].

You will be contact[**Name (NI) **] to set up a second attempt at
cardioversion and follow up echocardiogram planned for [**1-19**]
weeks.  If you do not hear in week, please call [**Telephone/Fax (1) 62**] and
ask for Jassen [**Doctor Last Name 7086**].

You had requested a referral for a cardiologist.  You could see

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 41711**], [**Last Name (NamePattern5) 41712**]
[**Location (un) 3320**], [**Numeric Identifier 34852**]
Phone:  ([**Telephone/Fax (1) 5319**] Ext.3822

We would recommend follow up in the next 4 weeks.

You should also follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41710**], in [**1-20**]
weeks.
{'Ventricular fibrillation,Septicemia due to pseudomonas,Pneumonia due to other gram-negative bacteria,Ventilator associated pneumonia,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Acute on chronic combined systolic and diastolic heart failure,Septic shock,Toxic encephalopathy,Severe sepsis,Mixed acid-base balance disorder,Aneurysm of heart (wall),Other and unspecified infection due to central venous catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac pacemaker in situ,Pressure ulcer, stage II,Other abnormal glucose,Anemia, unspecified,Aortocoronary bypass status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: Cardiac arrest

PRESENT ILLNESS: The patient is a 76 year old male with a history of CAD s/p
CABG, HTN, AF, syncope s/p PPM who presents following
out-of-hospital cardiac arrest. The patient has been noted to be
slightly dysnpic over the last two days. He has not experienceid
any chest pain, palpitations, light-headnedness, or any other
symtpoms. On the day of presenation, the patient went out to do
errands. He had spoken to his wife pulling into a wall-mart
parking lot, and did not make any notable complaints. He was
found down in the parking lot unresponsive. The event was
unwitnessed. Security was called, who placed an AED on the
patient, and fired twice for a shockable rhythm. EMS was
activated. From being found down to confirmation of a purfusing
rhythm, the estimated time down is roughly ten minutes.
He was intubated in the field and transfered to [**Hospital3 6592**].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2182**] by Dr. [**Last Name (STitle) 4026**]
[**Name (STitle) 41709**] CORONARY INTERVENTIONS:
-PACING/ICD: PPM placed in [**2189**] following syncopal event
3. OTHER PAST MEDICAL HISTORY:
.
Atrial Fibrillation

MEDICATION ON ADMISSION: Warfarin 2mg daily
Lisinorpil 20mg daily
Zocor 10mg daily
HCTZ 25mg daily
Fishoil 1000mg TID

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=96 BP= 123/71 HR= 60 RR= 16 O2 sat= 100% AC TV 600/5/40%
GENERAL: Elderly male, intubated, sedated, unresponsive. In
C-colllar.
HEENT: NCAT. PERRL (3mm to 2mm), in C-collar.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Scar on left leg and
arm.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Neuro: Absenct corneal reflex, down going babinski, no clonus,
opens eyes to name calling

FAMILY HISTORY: 

SOCIAL HISTORY: Married, former 

### Response:
{'Ventricular fibrillation,Septicemia due to pseudomonas,Pneumonia due to other gram-negative bacteria,Ventilator associated pneumonia,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Anoxic brain damage,Acute on chronic combined systolic and diastolic heart failure,Septic shock,Toxic encephalopathy,Severe sepsis,Mixed acid-base balance disorder,Aneurysm of heart (wall),Other and unspecified infection due to central venous catheter,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac pacemaker in situ,Pressure ulcer, stage II,Other abnormal glucose,Anemia, unspecified,Aortocoronary bypass status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
