CHIEF COMPLAINT: Chest Pain/Shortness of Breath
CHF,demand ischemia

PRESENT ILLNESS: Patient is an 85 year old man recently admitted to [**Hospital1 18**] in
[**2137-1-20**] for bilateral lower lobe pneumonia complicated by a
NSTEMI. Patient has reported history of untreated multiple MIs
in the [**2111**] and has diagnoses of HTN, CKD, CHF, DVT,and bipolar
disorder. On last admission, the patient had an echocardiogram
that revealed an EF 40-50% with global LV hypokinesis. The
cardiology service was consulted at this time with
recommendation that the patient was likely a poor cath candidate
given his multiple comorbidities and CKD with creatinine of 2.5
The patient was discharged back to his home at Heathwood NH with
decision to manage patient's cardiac disease medically. Per
notes from E.D. the patient is reported to have experienced
chest pain and dyspnea early this a.m. that was relieved at that
time with SL-NTG x1. The patient's symptoms recurred and was
treated again with nitropaste as well as lasix 120mg PO, without
resolution of symptoms this time. Given his symptoms, the
patient was trasnferred to [**Hospital1 18**] where he was found to be
tachypnic and dyspneic on arrival. In the ED, the patient was
treated with ASA 325mg, 80mg IV lasix, O2, NTG gtt and was
started on non-invasive ventilation, with reported resolution of
pain. The patient was treated with an additional 160mg IV lasix
without good initial response. Upon transfer to the CCU, the
patient had produced only 300cc urine.
.
Allergies: NKDA

MEDICAL HISTORY: 1. HTN
2. CKD: Cr from office visit last year w/ Cr 1.8
3. bipolar disorder - on lithium previously, recently
experienced toxicity
4. hyperlipidemia
5. prostrate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not

MEDICATION ON ADMISSION: Depakote: 250mg EC qhs, 125mg qam
Lasix 60mg po qd
Norvasc 10mg po qd
Plavix 75mg po qd
Hydralazine 75mg po qd
Protonix 40mg po qd
Lipitor 80mg po qd
ASA 81mg po qd
Coumadin 5mg po qhs
Toprol XL 225mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: BP: 118/59  HR: 77 (NSR)  RR: 31-32  O2 Sat: 96% on 4L
NC
.
Gen: Patient is an elderly male, sitting upright in bed in
moderate respiratory distress, with use of accessory muscles
when breathing and audible wheezes.
HEENT: NC, patient with small dry blood over left lower lip. MM:
dry
Neck: prominent EJ, + JVD
Chest: Noteable for use of sternocleidomastoids and intercostal
muscles with breathing. Patient with audible expiratory wheezes
from upper airway, asucultation of lung fields without
significant wheezes. Rapid breathing with small tidal volume,
poor airmovement throughout. Small crackles at left lower base
Cor: RRR, no obvious M/R/G
Abd: Obese, soft, NT. +NABS
Ext: 2+ pedal edema, 1+ pitting edema to knees. Chronic
hyperpigmentation of lower extremities bilaterally. Distal
pulses 2+ bilaterally.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. The patient is reported to be
independent of ADLs. He receives prepared meals twice daily via
the home facility. He reports that at baseline he is able to
ambulate although only with the aid of a walker on wheels. He
denies any drinking history and has very remote tobacco use. Has
2 grown children, one is [**State **] and one in [**State 760**]. Dr.
[**Last Name (STitle) 1266**] is the patient's PCP and his wife his HCP. Dr.
[**Last Name (STitle) 1266**] has been very involved with this patient regarding
code status and goals of care. Currently, the patient is full
code as was established on last admission and confirmed this
admission. Given patient's overall prognosis and expectation
that the patient will require more and more frequent
hospitalization, conversation is ongoing with regards to overall
management strategies.
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Anemia, unspecified,Bipolar I disorder, most recent episode (or current) unspecified
Subendo infarct, initial,Ac on chr syst hrt fail,Atrial fibrillation,Hyp kid NOS w cr kid V,Pneumonia, organism NOS,Urin tract infection NOS,Acute kidney failure NOS,Chronic kidney dis NOS,Long-term use anticoagul,Anemia NOS,Bipolor I current NOS
Admission Date:  [**2137-3-3**]              Discharge Date:   [**2137-3-8**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Chest Pain/Shortness of Breath
CHF,demand ischemia

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Patient is an 85 year old man recently admitted to [**Hospital1 18**] in
[**2137-1-20**] for bilateral lower lobe pneumonia complicated by a
NSTEMI. Patient has reported history of untreated multiple MIs
in the [**2111**] and has diagnoses of HTN, CKD, CHF, DVT,and bipolar
disorder. On last admission, the patient had an echocardiogram
that revealed an EF 40-50% with global LV hypokinesis. The
cardiology service was consulted at this time with
recommendation that the patient was likely a poor cath candidate
given his multiple comorbidities and CKD with creatinine of 2.5
The patient was discharged back to his home at Heathwood NH with
decision to manage patient's cardiac disease medically. Per
notes from E.D. the patient is reported to have experienced
chest pain and dyspnea early this a.m. that was relieved at that
time with SL-NTG x1. The patient's symptoms recurred and was
treated again with nitropaste as well as lasix 120mg PO, without
resolution of symptoms this time. Given his symptoms, the
patient was trasnferred to [**Hospital1 18**] where he was found to be
tachypnic and dyspneic on arrival. In the ED, the patient was
treated with ASA 325mg, 80mg IV lasix, O2, NTG gtt and was
started on non-invasive ventilation, with reported resolution of
pain. The patient was treated with an additional 160mg IV lasix
without good initial response. Upon transfer to the CCU, the
patient had produced only 300cc urine.
.
Allergies: NKDA

Past Medical History:
1. HTN
2. CKD: Cr from office visit last year w/ Cr 1.8
3. bipolar disorder - on lithium previously, recently
experienced toxicity
4. hyperlipidemia
5. prostrate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not

know details.
7. Urinary incontinence
8. MI ([**2111**]) and a recent NSTEMI in [**Month (only) **]/06
9. DVT
10. CHF

Social History:
Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. The patient is reported to be
independent of ADLs. He receives prepared meals twice daily via
the home facility. He reports that at baseline he is able to
ambulate although only with the aid of a walker on wheels. He
denies any drinking history and has very remote tobacco use. Has
2 grown children, one is [**State **] and one in [**State 760**]. Dr.
[**Last Name (STitle) 1266**] is the patient's PCP and his wife his HCP. Dr.
[**Last Name (STitle) 1266**] has been very involved with this patient regarding
code status and goals of care. Currently, the patient is full
code as was established on last admission and confirmed this
admission. Given patient's overall prognosis and expectation
that the patient will require more and more frequent
hospitalization, conversation is ongoing with regards to overall
management strategies.

Full code. Wife is his health care
proxy.
.


Family History:
Non-contributory

Physical Exam:
Physical Exam:
Vitals: BP: 118/59  HR: 77 (NSR)  RR: 31-32  O2 Sat: 96% on 4L
NC
.
Gen: Patient is an elderly male, sitting upright in bed in
moderate respiratory distress, with use of accessory muscles
when breathing and audible wheezes.
HEENT: NC, patient with small dry blood over left lower lip. MM:
dry
Neck: prominent EJ, + JVD
Chest: Noteable for use of sternocleidomastoids and intercostal
muscles with breathing. Patient with audible expiratory wheezes
from upper airway, asucultation of lung fields without
significant wheezes. Rapid breathing with small tidal volume,
poor airmovement throughout. Small crackles at left lower base
Cor: RRR, no obvious M/R/G
Abd: Obese, soft, NT. +NABS
Ext: 2+ pedal edema, 1+ pitting edema to knees. Chronic
hyperpigmentation of lower extremities bilaterally. Distal
pulses 2+ bilaterally.

Pertinent Results:
Admission Labs:
.
[**2137-3-3**] 11:40AM URINE  RBC-0-2 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2137-3-3**] 11:40AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2137-3-3**] 11:40AM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011
[**2137-3-3**] 11:40AM   PT-43.1* PTT-31.8 INR(PT)-4.9*
[**2137-3-3**] 11:40AM   NEUTS-95.2* BANDS-0 LYMPHS-3.1* MONOS-1.5*
EOS-0.2 BASOS-0
[**2137-3-3**] 11:40AM   WBC-16.8* RBC-3.53* HGB-11.0* HCT-32.6*
MCV-92 MCH-31.3 MCHC-33.9 RDW-14.7
[**2137-3-3**] 11:40AM   VALPROATE-11*
[**2137-3-3**] 11:40AM   CALCIUM-8.9 PHOSPHATE-6.1*# MAGNESIUM-2.4
[**2137-3-3**] 11:40AM   CK-MB-4
[**2137-3-3**] 11:40AM   cTropnT-0.13*
[**2137-3-3**] 11:40AM   CK(CPK)-170
[**2137-3-3**] 11:40AM   GLUCOSE-121* UREA N-45* CREAT-2.5* SODIUM-138
POTASSIUM-7.0* CHLORIDE-107 TOTAL CO2-18* ANION GAP-20
[**2137-3-3**] 12:00PM   ALBUMIN-4.0
[**2137-3-3**] 12:00PM   POTASSIUM-4.4
[**2137-3-3**] 12:03PM   LACTATE-1.7
[**2137-3-3**] 12:03PM   COMMENTS-GREEN TOP
[**2137-3-3**] 03:12PM   %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
[**2137-3-3**] 05:40PM   CK-MB-22* MB INDX-10.4* cTropnT-0.48*
[**2137-3-3**] 05:40PM   CK(CPK)-212*
[**2137-3-3**] 07:23PM   O2 SAT-97
[**2137-3-3**] 07:23PM   K+-4.0
[**2137-3-3**] 07:23PM   TYPE-ART PO2-87 PCO2-33* PH-7.43 TOTAL CO2-23
BASE XS-0
[**2137-3-3**] 08:04PM   CALCIUM-8.9 MAGNESIUM-2.1
[**2137-3-3**] 08:04PM   POTASSIUM-4.0
Pertinent Labs/Studies
.
CK: 170 -> 212 -> 224 -> 138
CK-MB: 4 -> 22 -> 23 -> 13
Trop: < .01 -> .48 -> .13
.
Creatinine: 2.5 -> 2.6 -> 2.7 -> 2.9
.
[**2137-3-3**]: HbA1c - 5.4%
[**2137-3-3**]: Valproate - 11
[**2137-3-3**]: CCU admission ABG: 7.43/33/87/23
.
.
Imaging:
[**2137-3-3**]: Portable Chest - There is stable cardiomegaly.  The
left
costophrenic angle is excluded from the radiograph.  There is
slight
prominence of the pulmonary vasculature centrally but no overt
edema.  Again identified is bibasilar opacification persisting
at the lung bases slightly increased in the left lower lobe
compared to the prior study which could be residual edema or
atelectasis.  The possibility of mild volume overload or
developing infection cannot be excluded.  No pneumothorax is
identified.  The soft tissue and osseous structures are stable.

IMPRESSION:  Slight increase in opacification at the lung bases
reflecting
bibasilar atelectasis or possible developing infection/mild
volume overload.
.
[**2137-3-5**]: Chest Pa/Lat - pending
.
.
Microbiology:
Urine Cultures:
[**2137-3-3**]: UA: Leuks Mod, Nit neg, WBC > 50, Bact - mod
[**2137-3-5**]: UA: Leuks Mod, Nit neg, WBC [**3-24**], Bact - few
[**2137-3-3**]: Urine Cx: >100K Coag Pos Staph
[**2137-3-5**]: Urine Cx: pending
.
Blood Cultures:
[**2137-3-3**]: Blood Cultures x 4: NGTD
[**2137-3-5**]: pending
Discharge Labs:

Brief Hospital Course:
Assessment: Patient is an 85 year old male with past CAD hx who
presents with CHF exacerbation and enzyme leak likely secondary
to demand ischemia.
.
Cardiovascular:
CHF:  The patient presented to the hospital with symptoms of
decompensated CHF including dyspnea, rales on exam and
peripheral edema. The patient additionally reported chest pain
on admission that was initially responsive to nitrate therapy,
then refractory. In the ED the patient was assessed to be in CHF
and was treated with lasix, 120mg IV in total, nitro gtt, and
additionally given aspirin given chest pain and history of CAD.
The patient was noted on admission to have an supratherapeutic
INR of 5.1 on admission for which additional anticoagulation
with Heparin gtt or Lovenox was held. The patient's ECG on
admission was remarkable for an old LBBB with some non-specific
TWI in I and aVL, poor R wave progression but no significant or
acute ST changes. The patient was admitted to the CCU for
ongoing diuresis with additional monitoring of enzymes for
potential NSTEMI. Of note, in the ED the patient was initially
treated with non-invasive mask ventilation with good effect.
Attempted diuresis prior to admission only yielded an output of
300cc net negative. Despite this, the patient was transferred to
the floor without need for non-invasive ventilation and was
oxygenating well with 5L NC. The patient was placed on a lasix
gtt with good effect with negative diuresis 2.5-3.0 liters since
admission. The patient remains mildly fluid overloaded with goal
additional diuresis of approximately one more liter, which will
be performed now with lasix boluses. Further diuresis beyond one
liter may be limited by the patient's renal function given rise
in creatinine from 2.5 to 2.9 as well as blood pressure. The
patient has had a steady oxygen requirement of 2.0 L NC with
some improvement in subjective symptoms. It is thought that
patient may do well on discharge with combination
Hydralazine/Nitrate for afterload/preload reduction as his
creatinine will not tolerate an ACE inhibitor.
.
CAD: As noted, on admission the patient was known to reportedly
have had multiple MIs in the 80's without intervention. The
patient's initial cardiac enzymes on admission were CK-170,
MB-4, Trop- .13 with peak values of 224/23/.48. Rise in
patient's enzymes were thought most likely to be secondary to
demand ischemia in the setting of decompensated CHF although a
small NSTEMI can not be [**Month/Day/Year 20003**] out. Trying to illicit the
precipitating event was unsuccessful. The patient on admission
was maintained on ASA and Plavix (which he was previously
taking). Heparin was not started given patient's elevated INR on
admission and coumadin was held. Patient was maintained on high
dose Atorvastatin for secondary prevention. The patient remained
chest pain free for the remainder of his admission. The patient
had an echocardiogram performed in [**Month (only) 404**] during his last
admission which demonstrated an EF of 40-50% with global LV
hypokinesis. Given there was no evidence for large infarct,
there was no expectation of any great change from previous, so a
repeat echocardiogram was not performed.  Pt in the past has not
been able to tolerate an ACEi due to worsening renal function
every time an ACE is started.
.
Rhythm: The patient on admission was in NSR without significant
ectopy during his hospital course. The patient however was noted
to develop afib on [**2137-3-4**] without clear precipitant. The
patient was normotensive without ongoing evidence of ischemia at
this time. The patient has no chart diagnosis of Afib but it is
possible or likely that he has paroxysmal afib that has not
previously been recognized. THe patient is currently already
anticoagulated for an indication of DVT. Given his age and
medical status, the patient is thought likely to be a poor
candidate for cardioversion. Therefore, current strategy is to
continue anticoagulation (INR goal 2.0-3.0) and rate control.
Currently the patient has had fair rate control with HR ranging
from 60-110. The patient's dose of hydralazine was decreased to
50mg po 6h to allow increase in metoprolol to 75mg po tid for
increased rate control. His rate is now well controlled with a
heart rate ranging from 60-80s.
.
#. ID - The patient remained afebrile without elevated white
count on admission. On previous admission the patient was
treated for PNA. On admission to CCU, patient was noted to have
+UA as well as questionable left lower lobe consolidation worse
than previous for which levo/Flagyl was started. Flagyl was
discontinued the following day given no evidence for aspiration
or PNA and the patient was continued on levofloxacin for pna to
complete a ten day course. Urine culture from [**2137-3-3**] grew Coag
+ Staph, sensitivity pending. Given foley, it was thought this
more likely represented contaminant or colonizer so abx regimen
was not changed. The patient's foley catheter was changed and
repeat UA/UCx ordered. The patient had one set of blood culture
without growth and a repeat was ordered to ensure there was no
seeding of urine from blood. The bacteria was later identified
as MRSA and patient was treated with 2 days of IV Vancomycin,
and transitioned to Linezolid PO to complete a 1 week course.
.
#. Heme: On admission the patient was noted to have a
supratherapeutic INR of 5.1 for which coumadin was held. Despite
this, the patient's INR continued to rise to 7.0 over two days.
This was thought most likely to be nutritional and the patient
was given 5mg PO Vitamin K on [**2137-3-5**]. Also of note the patient
had a HCt drop from 32.6 on admission to 27.7. However, repeat
Hct have been relatively stable and the patient is without any
obvious source of bleeding (no bowel movements yet this
admission). INR dropped to 1.4 after administration of Vit K and
patient was restarted on his coumadin at a dose of 4mg po qhs.
Pt is have his INR monitored by his PCP and dose will be
titrated as needed to maintain goal of [**2-22**].
.
#. CKD: Patient is noted to have baseline creatinine of 2.0-2.8.
On admission the patient had a creatinine of 2.5 which has been
rising, most recently 2.9 in the setting of diuresis. Patient's
meds have been reneally dosed and current diuresis plans are to
remove approximately one additional liter given rising
creatinine and potential for hypotension.  Pt's creatinine
eventually peaked at 3.1, and with continued diuresis, pt's Cr
dropped to 2.6 on day of discharge, which is patient's baseline.

.
#. FEN: Patient was maintained on a Cardiac Healthy/Low Na diet.
Patient had a S+S eval which cleared his as appropriate for thin
liquids and puree solids with appropriate aspiration precautions
and assistance with feeding. Patient is being fluid restricted <
1200 given CHF.
.
#. Code: Full.
#  DISPO: Patient to be discharged to rehabilitation for short
term rehab.

Medications on Admission:
Depakote: 250mg EC qhs, 125mg qam
Lasix 60mg po qd
Norvasc 10mg po qd
Plavix 75mg po qd
Hydralazine 75mg po qd
Protonix 40mg po qd
Lipitor 80mg po qd
ASA 81mg po qd
Coumadin 5mg po qhs
Toprol XL 225mg po qd

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Divalproex 250 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO HS (at bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
11. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO three
times a day: with meals.
17. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 2670**] - [**Location (un) **]

Discharge Diagnosis:
Primary:
1. Decompansated CHF
2. ? Demand ischemia vs. small NSTEMI
3. UTI (MRSA)
Secondary:
4. Coronary artery disease
5. Hypertension
6. Chronic renal insufficency
7. Anemia
8. DVT

Discharge Condition:
Afebrile, pain free, stable to be discharged home

Discharge Instructions:
1.  Please report to the nearest emergency department if you
have
fever, shortness of breath, chest pain or loss of consciousness.


2.  Please weigh yourself daily. Please call Dr. [**Last Name (STitle) 1266**] if
you gain more than 3 lbs.

3.  Please limit your fluid intake to 1200 ml daily

4.  Please follow up with the following providers:
A. Primary Care
Please make an appointment to followup with Dr. [**Last Name (STitle) 1266**] within

the next 2 weeks. You can reach his office at [**Telephone/Fax (1) 608**].
B. Cardiology: Please call to schedule an appointment to be seen

within 1 month ([**Telephone/Fax (1) 62**]) for follow-up of congestive heart
failure
C. [**Telephone/Fax (1) **] Surgery
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) (see
appointment time below)
D. Podiatry
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2137-3-15**] 10:00
Provider: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2137-4-26**] 2:20
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2137-7-30**] 10:30


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

Completed by:[**2137-3-8**]
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Anemia, unspecified,Bipolar I disorder, most recent episode (or current) unspecified'}


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: Chest Pain/Shortness of Breath
CHF,demand ischemia

PRESENT ILLNESS: Patient is an 85 year old man recently admitted to [**Hospital1 18**] in
[**2137-1-20**] for bilateral lower lobe pneumonia complicated by a
NSTEMI. Patient has reported history of untreated multiple MIs
in the [**2111**] and has diagnoses of HTN, CKD, CHF, DVT,and bipolar
disorder. On last admission, the patient had an echocardiogram
that revealed an EF 40-50% with global LV hypokinesis. The
cardiology service was consulted at this time with
recommendation that the patient was likely a poor cath candidate
given his multiple comorbidities and CKD with creatinine of 2.5
The patient was discharged back to his home at Heathwood NH with
decision to manage patient's cardiac disease medically. Per
notes from E.D. the patient is reported to have experienced
chest pain and dyspnea early this a.m. that was relieved at that
time with SL-NTG x1. The patient's symptoms recurred and was
treated again with nitropaste as well as lasix 120mg PO, without
resolution of symptoms this time. Given his symptoms, the
patient was trasnferred to [**Hospital1 18**] where he was found to be
tachypnic and dyspneic on arrival. In the ED, the patient was
treated with ASA 325mg, 80mg IV lasix, O2, NTG gtt and was
started on non-invasive ventilation, with reported resolution of
pain. The patient was treated with an additional 160mg IV lasix
without good initial response. Upon transfer to the CCU, the
patient had produced only 300cc urine.
.
Allergies: NKDA

MEDICAL HISTORY: 1. HTN
2. CKD: Cr from office visit last year w/ Cr 1.8
3. bipolar disorder - on lithium previously, recently
experienced toxicity
4. hyperlipidemia
5. prostrate surgery many years ago - indication not specified
6. Patient reports hospitalization in [**2111**]'s for MI but does not

MEDICATION ON ADMISSION: Depakote: 250mg EC qhs, 125mg qam
Lasix 60mg po qd
Norvasc 10mg po qd
Plavix 75mg po qd
Hydralazine 75mg po qd
Protonix 40mg po qd
Lipitor 80mg po qd
ASA 81mg po qd
Coumadin 5mg po qhs
Toprol XL 225mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: BP: 118/59  HR: 77 (NSR)  RR: 31-32  O2 Sat: 96% on 4L
NC
.
Gen: Patient is an elderly male, sitting upright in bed in
moderate respiratory distress, with use of accessory muscles
when breathing and audible wheezes.
HEENT: NC, patient with small dry blood over left lower lip. MM:
dry
Neck: prominent EJ, + JVD
Chest: Noteable for use of sternocleidomastoids and intercostal
muscles with breathing. Patient with audible expiratory wheezes
from upper airway, asucultation of lung fields without
significant wheezes. Rapid breathing with small tidal volume,
poor airmovement throughout. Small crackles at left lower base
Cor: RRR, no obvious M/R/G
Abd: Obese, soft, NT. +NABS
Ext: 2+ pedal edema, 1+ pitting edema to knees. Chronic
hyperpigmentation of lower extremities bilaterally. Distal
pulses 2+ bilaterally.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient lives with his wife of > 60 years in an [**Hospital3 **]
senior facility in [**Location (un) **]. The patient is reported to be
independent of ADLs. He receives prepared meals twice daily via
the home facility. He reports that at baseline he is able to
ambulate although only with the aid of a walker on wheels. He
denies any drinking history and has very remote tobacco use. Has
2 grown children, one is [**State **] and one in [**State 760**]. Dr.
[**Last Name (STitle) 1266**] is the patient's PCP and his wife his HCP. Dr.
[**Last Name (STitle) 1266**] has been very involved with this patient regarding
code status and goals of care. Currently, the patient is full
code as was established on last admission and confirmed this
admission. Given patient's overall prognosis and expectation
that the patient will require more and more frequent
hospitalization, conversation is ongoing with regards to overall
management strategies. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Anemia, unspecified,Bipolar I disorder, most recent episode (or current) unspecified'}
