CHIEF COMPLAINT: fever, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 13972**] is a 72M with CAD h/o CABG (LIMA-LAD, SVG-OM,
SVG-Ramus, [**2102**], last cath [**3-29**] with 3VD patent LIMA to LAD,
patent SVG to OM, patent SVG to R1, but R1 terminates after
touchdown point, no intervention), paroxysmal afib (last episode
of PAF in [**7-29**] with trop leak), PVD, DM2 and ESRD on HD & PD
s/p HD day of admission (removal of 4L) presents to ED with
fever to 102, hypotension, and AF with RVR.  He had recently
been seen by his PMD for LE cellulitis and was given an rx for
Augmentin x 1 day.  He denies any chest pain, LH, dizziness,
palpitations.  He reports a HA which is not unusual for him
after HD.  Per his wife he has had persistent diarrhea for the
past month, [**1-27**] loose stool/day.  He also suffers from
post-prandial nausea which has been present for months.  He has
a chronic cough and reports worsening DOE for past 3-4 months.
Known to have low SBP (SBP 85/40 in clinic).
.
In the ED the patient had temperature to 102, ventricular rate
in 100s, BP 79/47.  He was given gentle IVF, flagyl, vancomycin,
and ceftriaxone.  He was started on amiodarone load 150mg,
followed by amiodarone 1mg/min gtt.  CXR showed ? aspiration
PNA, unable to send PD fluid for culture as pt was empty.

MEDICAL HISTORY: 1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

MEDICATION ON ADMISSION: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY.
2. Megestrol 20 mg Tablet Sig: One (1) Tablet PO QD
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QOD ().
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet, 1 Tablet PO QPM
9. Metoprolol Tartrate 50 mg Tablet, 1 tablet PO QAM
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QD
11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Sulfonamides / Amlodipine / Percocet

PHYSICAL EXAM: VS 101.4 BP 85/37 HR 82 RR 22 O2sat 91%
Gen: AAOx3, moaning in pain, somnolent
HEENT: dry MM, EOMI, PERRL
neck: JVD to 15cm
CVR: normal s1s2, 2/6 systolic ejection murmur.
Chest: Tunneled HD catheter on right chest, some minimal
erythema around site.  No drainage or tenderness.
Lungs: Rhonchorous throughout.
Abd: NT/ND, bs normoactive, soft, PD dressed, clean.
Ext: tense RLE, erythematous, tender to palpation, warm.  LLE
s/p toe amputation.

FAMILY HISTORY: Father with DM type 2
Two sisters and one brother--all well

SOCIAL HISTORY: Patient has been married for 42 years with a supportive wife who
"visits me every single day I'm in the hospital and drives me to
dialysis." He expresses some anxiety regarding feeling like "a
burden" on his family.  He has two children, one 29 yo son who
is a financial analyst in [**Location (un) 21601**], and one older daughter who
is raising five children in [**Location (un) 30790**], [**State 2748**].  He is very
proud of his family.  He works as a pharmacist.  He used to own
his own pharmacies but sold them to [**Doctor First Name **] and has worked for
the past 18 years at the VA. He says the VA is "holding my job
for me." He has enjoyed golf and tennis in the past and his loss
of mobility has been difficult for him.  He is a former smoker,
denies alcohol and drug use.
Pneumonia, organism unspecified,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Congestive heart failure, unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status
Pneumonia, organism NOS,Cellulitis of leg,Atrial fibrillation,CHF NOS,End stage renal disease,DMII renl nt st uncntrld,Hypothyroidism NOS,Cor ath unsp vsl ntv/gft,Aortocoronary bypass
Admission Date:  [**2108-10-6**]              Discharge Date:   [**2108-10-12**]

Date of Birth:  [**2036-8-7**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfonamides / Amlodipine / Percocet

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
fever, hypotension

Major Surgical or Invasive Procedure:
Hemodialysis


History of Present Illness:
Mr. [**Known lastname 13972**] is a 72M with CAD h/o CABG (LIMA-LAD, SVG-OM,
SVG-Ramus, [**2102**], last cath [**3-29**] with 3VD patent LIMA to LAD,
patent SVG to OM, patent SVG to R1, but R1 terminates after
touchdown point, no intervention), paroxysmal afib (last episode
of PAF in [**7-29**] with trop leak), PVD, DM2 and ESRD on HD & PD
s/p HD day of admission (removal of 4L) presents to ED with
fever to 102, hypotension, and AF with RVR.  He had recently
been seen by his PMD for LE cellulitis and was given an rx for
Augmentin x 1 day.  He denies any chest pain, LH, dizziness,
palpitations.  He reports a HA which is not unusual for him
after HD.  Per his wife he has had persistent diarrhea for the
past month, [**1-27**] loose stool/day.  He also suffers from
post-prandial nausea which has been present for months.  He has
a chronic cough and reports worsening DOE for past 3-4 months.
Known to have low SBP (SBP 85/40 in clinic).
.
In the ED the patient had temperature to 102, ventricular rate
in 100s, BP 79/47.  He was given gentle IVF, flagyl, vancomycin,
and ceftriaxone.  He was started on amiodarone load 150mg,
followed by amiodarone 1mg/min gtt.  CXR showed ? aspiration
PNA, unable to send PD fluid for culture as pt was empty.

Past Medical History:
1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

ulcer on [**2-26**] s/p atherectomy of L SFA popliteal tbioperoneal
trunk with angioplasty x 2. Pt had recent right first toe
amputation and left TMA on [**2107-3-24**].
3)Paroxysmal atrial fibrillation
4)Type II DM: followed by [**Last Name (un) **]
5)Hyperlipidemia
6)Chronic bronchiectasis
7)EF 35%
p-MIBI [**2108-2-27**]: Mild-moderate anterior-lateral and apical
reversible defect. 2. Mild global hypokinesis and septal
akinesis. 3. Ejection fraction is 35%.
8)BPH
9)Anemia of chronic illness
10)CRI on daily peritoneal dialysis
.
PAST SURGICAL HISTORY:
1) s/p angioplasties of the left common femoral, superficial
femoral, tibioperoneal trunk in ([**2106-11-24**])
2) left CEA ([**2102**] at [**Hospital1 2025**])
3) CABG (LIMA to the LAD and saphenous vein graft to the
obtuse marginal 1 and the ramus intermedius - [**2103-9-24**])
4) s/p cholecystectomy with exploratory lap with repair of
liver lacerations ([**2105-11-23**])
5) PD catheter placement in ([**2106-9-24**])
6) right eye cataract with intraocular lens, right
eye vitrectomy
7) right common femoral artery to posterior
tibial bypass graft with in situ saphenous vein in [**Month (only) 404**] of
[**2106**].


Social History:
Patient has been married for 42 years with a supportive wife who
"visits me every single day I'm in the hospital and drives me to
dialysis." He expresses some anxiety regarding feeling like "a
burden" on his family.  He has two children, one 29 yo son who
is a financial analyst in [**Location (un) 21601**], and one older daughter who
is raising five children in [**Location (un) 30790**], [**State 2748**].  He is very
proud of his family.  He works as a pharmacist.  He used to own
his own pharmacies but sold them to [**Doctor First Name **] and has worked for
the past 18 years at the VA. He says the VA is "holding my job
for me." He has enjoyed golf and tennis in the past and his loss
of mobility has been difficult for him.  He is a former smoker,
denies alcohol and drug use.

Family History:
Father with DM type 2
Two sisters and one brother--all well


Physical Exam:
VS 101.4 BP 85/37 HR 82 RR 22 O2sat 91%
Gen: AAOx3, moaning in pain, somnolent
HEENT: dry MM, EOMI, PERRL
neck: JVD to 15cm
CVR: normal s1s2, 2/6 systolic ejection murmur.
Chest: Tunneled HD catheter on right chest, some minimal
erythema around site.  No drainage or tenderness.
Lungs: Rhonchorous throughout.
Abd: NT/ND, bs normoactive, soft, PD dressed, clean.
Ext: tense RLE, erythematous, tender to palpation, warm.  LLE
s/p toe amputation.

Pertinent Results:
Admit labs:
[**2108-10-6**]
Trop-*T*: 0.18
Comments: Corrected Result
Previously Reported As 1.83
Notified [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3510**] At 1640 On [**2108-10-7**]-Pap
Ctropnt > 0.10 Ng/Ml Suggests Acute Mi

141  102  28     AGap=12
-------------< 116
4.0  31  2.0
CK: 71  MB: Notdone
Ca: 7.5 Mg: 1.5 P: 2.9 D
ALT: 21 AP: 107 Tbili: 0.5 Alb:
AST: 19 LDH:  Dbili:  TProt:
[**Doctor First Name **]: 5 Lip:
            106
11.4 \ 12.6 / 252
     / 38.7 \

 N:83 Band:5 L:3 M:6 E:2 Bas:0 Atyps: 1
PT: 21.4  PTT: 117.2  INR: 2.1

Past cardiology studies:

[**2108-2-27**] Persantine MIBI: IMPRESSION: 1. Mild-moderate
anterior-lateral and apical reversible defect.  2. Mild global
hypokinesis and septal akinesis.  3. Ejection fraction is 35%.
.
Cath [**2106-12-22**]:
R dominant system
LMCA: 60% occluded
LAD: widely patent LIMA to LAD. SVG to RI 80% ostial
LCX: patent SVG to OM. LCX 80% prox.
RCA: proximally occluded, filled by collaterals from LIMA/SVG
.
Cath [**2108-3-28**]
1. Selective coronary angiography in this right dominant
circulation
demonstrated severe native vessel coronary artery disease. The
LMCA was diffusely diseased with 60% distal stenosis. The LAD
was totally
occluded in the proximal segement. The distal LAD had mild
disease and was supplied by the LIMA graft. The LCx had severe
diffuse disease. The OM and Ramus were totally occluded at their
origins, but filled via an SVG.
2. Saphenous vein angiography demonstrated widely patent SVG to
OM and SVG to Ramus. The Ramus was totally occluded after the
touchdown point and filled via collaterals from the grafted OM.
3. Arterial conduit arteriography demonstrated a widely patent
LIMA to LAD.
4. Opening pressure in the central aorta was moderately
elevated.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM.
4. Patent SVG to Ramus, but total occlusion after touchdown
point.
.
PFTs [**2105-4-8**]:
FEV1 58% predicted, FEV1/FVC 96%. c/w restrictive pattern.
former smoker 1.5 pack per day x25 years, not smoked for 20 yrs

.
CURRENT STUDIES:

[**2108-10-6**] CXR: IMPRESSION:
1.  Increased left lower lobe opacity, which may represent
pneumonia, although atelectasis is possible.
2.  Right middle lobe opacity, highly suspicious for pneumonia.
3.  Worsening fluid overload with increased pulmonary
vascularity and small effusions.

Cardiology Report ECG Study Date of [**2108-10-6**]  4:08:18 PM
Atrial fibrillation with a mean ventricular response, rate 160.
Delayed
anterior precordial R wave progression. Marked inferolateral ST
segment
depression. Compared to the previous tracing of [**2108-8-19**] cardiac
rhythm now
rapid atrial fibrillation with repolarization abnormalities.

Norable labs during course:
TSH:4.3 Free-T4:1.1
Other Blood Chemistry:
T4: 4.6
T3: 62

Discharge labs:
[**2108-10-12**]
           103
8.6 \ 11.7 / 336
    / 36.4 \

PT: 21.6  PTT: 35.0  INR: 2.1


Brief Hospital Course:
This is a 72 year old M with h/o ESRD s/p HD day of admission
(took off 4.2L), severe PVD s/p multiple interventions,
paroxysmal AFib, CAD s/p CABG, CHF EF 30%, DM2, bronchiectasis
admitted to CCU with a-fib/RVR, self-converted to NSR, fever,
hypotension, and LE cellulitis.
.
CARDIAC
# Rhythm: Mr. [**Known lastname 13972**] has a history of paroxysmal Afib.  He
presented to the ED following hemodialysis in atrial
fibrillation, but hemodynamically stable.  He was also noted to
have a troponin leak.  He was given an esmolol drip in the ED
with no response, followed by an amiodarone load 150mg then
1mg/min drip.  On the way up to the CCU he converted back to
sinus rhythm.  This was attributed more to chance than to the
amiodarone as the patient takes amiodarone at home.  The patient
remained in sinus rhythm for the first 24 hours of his
hospitalization, however on hospital day 2 he flipped into rapid
atrial fibrillation with RVR.  This was terminated with PO and
IV metoprolol.  He continues to flip from Afib to sinus.  He
remained asymptomatic when he was in atrial fibrillation.  On
hospital day 1 he was placed back on his home PO amiodarone dose
of 200mg daily.  Beta blockers and ace inhibitors were held due
to his low blood pressures.  On HD2, his blood pressure rose and
he was restarted on low dose beta blocker.  On HD3 as the
patient continued to return to atrial fibrillation from sinus,
digoxin was started and his beta blocker was increased to QID.
The future need for PPM placement with AVJ ablation was
discussed with the patient, and can be considered by Dr.
[**Last Name (STitle) **] in follow up if A fib becomes a problem. [**Name (NI) **] will remain
on coumadin with INR goal [**1-27**].
.
# CAD: Mr. [**Known lastname 13972**] has known unrevascularized disease (ramus).
He remained chest pain free during the admission and was
continued on aspirin and a statin. His elevated troponin and CK
were felt to be secondary to demand ischemia in the setting of A
fib.
.
# LV function: Based on previous persantine MIBI, Mr. [**Known lastname 13972**]
has an EF of 35%.  His fluid status was carefully monitored in
the setting of ESRD and low EF.  He was placed on fluid
restriction.
.
Pneumonia/CHF
He presented with respiratory distress/CHF, likely secondary to
pulmonary edema
CXR consistent w/ pneumonia and perhaps some pulmonary edema. He
was treated with zosyn and vancomycin, and sputum culture showed
1 colony of MRSA which suggested a low burden of disease, adn
given his clinical improvement after hemodialysis with removal
of fluid, this pneumonia was not felt to be secondary to MRSA.

# Cellulitis
Had been treated with augmentin for LE cellulitis as outpatient,
now febrile with worsening cellulitis.  Source may be cellulitis
vs. PNA vs HD line. His cellulitis was improving on vanc/zosyn,
and he was changed to augmentin. If he does resolve in the next
week, he can be considered for vancomycin with dialysis for 14
days to cover MRSA.

# ESRD - The renal team followed and assisted with
ultrafiltration for removal of fluid. His peritoneal dialysis
was discontinued and he was moved to three times weekly
dialysis. His other dialysis medications were continued and
antibiotics were renally dosed.

# DM2 - He was maintained on NPH with sliding scale insulin, and
his regimen was tailored slightly.

# Hypothyroidism: Continue levothyroxine. His TSH was slightly
elevated, but given his hospitalization and the possibility of
sick euthyroid his TFTs should be rechecked as an outpatient..


Medications on Admission:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY.
2. Megestrol 20 mg Tablet Sig: One (1) Tablet PO QD
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QOD ().
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet, 1 Tablet PO QPM
9. Metoprolol Tartrate 50 mg Tablet, 1 tablet PO QAM
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QD
11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.

12. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
13. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
sprays to each nostril Nasal once a day as needed.
14. Niferex 60 mg Capsule Sig: Two (2) Capsule PO once a day: Do

not take with your levothyroxine.
15. Folic Acid  Oral
16. Renagel  Oral
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Fourteen (14) units Subcutaneous qam.
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Fourteen (14) units Subcutaneous at bedtime.
21. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: Per home insulin sliding scale.
22. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for pain.
23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*

Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily): may discontinue when cellulitis improved.
Disp:*30 Capsule(s)* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*30 Tablet(s)* Refills:*2*
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: as
directed as dir Subcutaneous four times a day: 16 units in
morning, 8 in evening with sliding scale of humalog (see
attached scale or resume your previous scale).
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO QODHS (every
other day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
13. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): take after hemodialysis for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
to be followed by your PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] confirm dose before taking
on hemodialysis days.
Disp:*30 Tablet(s)* Refills:*2*
15. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours as needed for pain.
16. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Lisinopril 2.5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*


Discharge Disposition:
Home with Service

Discharge Diagnosis:
Primary:
cellulitis
Congestive Heart Failure
Atrial fibrillation with rapid ventricular response and
myocardial strain
community aquired pneumonia

Secondary:
Coronary Artery Disease
Diabetes Mellitus
Peripheral vascular disease
End stage renal disease, on hemodialysis


Discharge Condition:
Good, off oxygen, felling well to go home


Discharge Instructions:
You were admitted to the hospital for congestive heart failure
and pneumonia. You had an abnormal heart rhythm called atrial
fibrillation that required some changes to your medications.

It is important you continue to take all of your medications as
prescribed. You were started on digoxin for your atrial
fibrillation, and doses of your other medications have been
changed.

Call Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **] or 911 if you experience
worsening shortness of breath, cough, fevers, chills, chest
pain, profuse sweating, severe leg pain or leg rash.

Check your weight daily and eat less than 2 grams salt daily.
Call your PCP if your weight increases by more than 5 pounds.

Followup Instructions:
Please follow up with your PCP [**Name9 (PRE) 3109**],[**Name9 (PRE) **] [**Telephone/Fax (1) 3110**] in
[**12-26**] weeks. They are aware that you are being discharged, and can
follow up your INR which will be drawn at dilaysis, with a goal
of [**1-27**]. He can also recheck your thyroid function tests in [**1-28**]
weeks.

Please follow up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4022**]. Call now for an
appointment in the next month.

Please follow up with Dr. [**First Name (STitle) 805**] at hemodialysis.
{'Pneumonia, organism unspecified,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Congestive heart failure, unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status'}


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: fever, hypotension

PRESENT ILLNESS: Mr. [**Known lastname 13972**] is a 72M with CAD h/o CABG (LIMA-LAD, SVG-OM,
SVG-Ramus, [**2102**], last cath [**3-29**] with 3VD patent LIMA to LAD,
patent SVG to OM, patent SVG to R1, but R1 terminates after
touchdown point, no intervention), paroxysmal afib (last episode
of PAF in [**7-29**] with trop leak), PVD, DM2 and ESRD on HD & PD
s/p HD day of admission (removal of 4L) presents to ED with
fever to 102, hypotension, and AF with RVR.  He had recently
been seen by his PMD for LE cellulitis and was given an rx for
Augmentin x 1 day.  He denies any chest pain, LH, dizziness,
palpitations.  He reports a HA which is not unusual for him
after HD.  Per his wife he has had persistent diarrhea for the
past month, [**1-27**] loose stool/day.  He also suffers from
post-prandial nausea which has been present for months.  He has
a chronic cough and reports worsening DOE for past 3-4 months.
Known to have low SBP (SBP 85/40 in clinic).
.
In the ED the patient had temperature to 102, ventricular rate
in 100s, BP 79/47.  He was given gentle IVF, flagyl, vancomycin,
and ceftriaxone.  He was started on amiodarone load 150mg,
followed by amiodarone 1mg/min gtt.  CXR showed ? aspiration
PNA, unable to send PD fluid for culture as pt was empty.

MEDICAL HISTORY: 1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing

MEDICATION ON ADMISSION: 1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY.
2. Megestrol 20 mg Tablet Sig: One (1) Tablet PO QD
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY
5. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QOD ().
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Metoprolol Tartrate 50 mg Tablet, 1 Tablet PO QPM
9. Metoprolol Tartrate 50 mg Tablet, 1 tablet PO QAM
10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO QD
11. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.

ALLERGIES: Sulfonamides / Amlodipine / Percocet

PHYSICAL EXAM: VS 101.4 BP 85/37 HR 82 RR 22 O2sat 91%
Gen: AAOx3, moaning in pain, somnolent
HEENT: dry MM, EOMI, PERRL
neck: JVD to 15cm
CVR: normal s1s2, 2/6 systolic ejection murmur.
Chest: Tunneled HD catheter on right chest, some minimal
erythema around site.  No drainage or tenderness.
Lungs: Rhonchorous throughout.
Abd: NT/ND, bs normoactive, soft, PD dressed, clean.
Ext: tense RLE, erythematous, tender to palpation, warm.  LLE
s/p toe amputation.

FAMILY HISTORY: Father with DM type 2
Two sisters and one brother--all well

SOCIAL HISTORY: Patient has been married for 42 years with a supportive wife who
"visits me every single day I'm in the hospital and drives me to
dialysis." He expresses some anxiety regarding feeling like "a
burden" on his family.  He has two children, one 29 yo son who
is a financial analyst in [**Location (un) 21601**], and one older daughter who
is raising five children in [**Location (un) 30790**], [**State 2748**].  He is very
proud of his family.  He works as a pharmacist.  He used to own
his own pharmacies but sold them to [**Doctor First Name **] and has worked for
the past 18 years at the VA. He says the VA is "holding my job
for me." He has enjoyed golf and tennis in the past and his loss
of mobility has been difficult for him.  He is a former smoker,
denies alcohol and drug use. 

### Response:
{'Pneumonia, organism unspecified,Cellulitis and abscess of leg, except foot,Atrial fibrillation,Congestive heart failure, unspecified,End stage renal disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status'}
