CHIEF COMPLAINT: Worsening shortness of breath with mild to moderate exertion

PRESENT ILLNESS: 84 year old male with history of MVP, moderate MR, mild AI, TR,
mild pulmonary hypertension on recent Echo complaining of
worsening shortness of breath.  He underwent a cardiac
catheterization at [**Hospital6 5016**] that showed three vessel
disease.  He was then transferred to [**Hospital1 18**] for further cardiac
evaluation and referral for cardiac revascularization.

MEDICAL HISTORY: CAD, with +ETT
MI [**19**] years ago
Hyperlipidemia
OA/osteoporosis
Chronic sinusitis
Rheumatoid arthritis
MVP with moderate MR
CRI

MEDICATION ON ADMISSION: Plavix 75mg (stopped [**2185-9-27**])
Benacor 20mg qd
Atenolol 12.5mg qd
Folic acid 1mg qd
flexeril 10mg qd
ultram 50mg qd
mvi qd
methotrexate 6 tabs each week

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: 84 year old male in NAD status post cardiac catheterization
lying in bed
HEENT- PERRL
CVS- S1/S2 no m/r/g
Pulm- B/S CTA
ABD-S/NT/ND
Vascular- no carotid bruits, varicosities.  Left groin hematoma
with distal pulses present, groin hematoma expanding on
admission

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at home with wife, denies alcohol or tobacco use (quit 40
years ago)
Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Urinary tract infection, site not specified,Other tracheostomy complications,Acute cholecystitis,Bacteremia,Unspecified intestinal obstruction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Mitral valve disorders,Atrial fibrillation,Infection with microorganisms resistant to penicillins,Intermediate coronary syndrome
Crnry athrscl natve vssl,CHF NOS,Acute respiratry failure,Ac kidny fail, tubr necr,Hyp kid NOS w cr kid V,Hematoma complic proc,Urin tract infection NOS,Tracheostomy comp NEC,Acute cholecystitis,Bacteremia,Intestinal obstruct NOS,Meth sus pneum d/t Staph,Mitral valve disorder,Atrial fibrillation,Inf mcrg rstn pncllins,Intermed coronary synd
Admission Date:  [**2185-9-28**]              Discharge Date:   [**2185-11-18**]


Service: CARDIOTHORACIC

Allergies:
Morphine Sulfate

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Worsening shortness of breath with mild to moderate exertion

Major Surgical or Invasive Procedure:
[**2185-10-4**] CABGx3.  Vein grafts to left anterior descending,
obtuse marginal one and two.  (Left internal mammary artery
without flow)
[**11-5**] Explor Lap/ open CCY and GJtube placement
[**11-8**] Permacath HD line placed
[**11-9**] Tracheostomy w takeback for bleeding


History of Present Illness:
84 year old male with history of MVP, moderate MR, mild AI, TR,
mild pulmonary hypertension on recent Echo complaining of
worsening shortness of breath.  He underwent a cardiac
catheterization at [**Hospital6 5016**] that showed three vessel
disease.  He was then transferred to [**Hospital1 18**] for further cardiac
evaluation and referral for cardiac revascularization.

Past Medical History:
CAD, with +ETT
MI [**19**] years ago
Hyperlipidemia
OA/osteoporosis
Chronic sinusitis
Rheumatoid arthritis
MVP with moderate MR
CRI


Social History:
Lives at home with wife, denies alcohol or tobacco use (quit 40
years ago)

Family History:
Noncontributory

Physical Exam:
84 year old male in NAD status post cardiac catheterization
lying in bed
HEENT- PERRL
CVS- S1/S2 no m/r/g
Pulm- B/S CTA
ABD-S/NT/ND
Vascular- no carotid bruits, varicosities.  Left groin hematoma
with distal pulses present, groin hematoma expanding on
admission

Pertinent Results:
[**2185-10-1**] 05:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2185-10-1**] 05:57PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2185-10-1**] 05:57PM URINE RBC-[**4-29**]* WBC-[**10-9**]* Bacteri-FEW
Yeast-NONE Epi-0
[**2185-9-28**] 07:43PM   WBC-14.8* RBC-2.56* HGB-7.8* HCT-24.1* MCV-94
MCH-30.6 MCHC-32.5 RDW-16.9*
[**2185-9-28**] 07:43PM   GLUCOSE-148* UREA N-23* CREAT-1.5* SODIUM-140
POTASSIUM-5.2* CHLORIDE-112* TOTAL CO2-17* ANION GAP-16
[**2185-9-28**] 09:21PM   TYPE-ART PO2-154* PCO2-25* PH-7.43 TOTAL
CO2-17* BASE XS--5
[**2185-9-28**] 10:03PM   ALT(SGPT)-13 AST(SGOT)-15 LD(LDH)-168
CK(CPK)-53 ALK PHOS-54 TOT BILI-0.4

CT ABDOMEN W/O CONTRAST  [**2185-9-28**] 8:53 PM
REASON FOR THIS EXAMINATION:r/o retroperitoneal hematoma
IMPRESSION:
1. No evidence for retroperitoneal hematoma.
2. Right inguinal hernia containing a small section of small
bowel at its proximal most aspect. No evidence for bowel
obstruction or ischemia.
3. Diffuse atherosclerotic disease throughout the aorta.

CAROTID SERIES COMPLETE  [**2185-9-29**] 10:49 AM
Reason: PRE-OP CABG assess for stenosis
HISTORY: 84-year-old man preop CABG, assess for stenosis. Right
IJV line.
FINDINGS: The cervical portions of the carotid and vertebral
arteries were examined with duplex ultrasound bilaterally.
Wall thickening is present in the right carotid artery. The peak
systolic velocities of the right internal, common, and external
carotid arteries are 72, 47 and 43 cm/sec respectively. The
right ICA-CCA ratio is 1.53.
Mild wall thickening is seen in the left carotid artery. The
peak systolic velocities of the left internal, common, and
external carotid arteries are 64, 61 and 46 cm/sec respectively.
The left ICA-CCA ratio is 1.04.
There is appropriate antegrade flow in the left vertebral
artery. The right vertebral artery could not be visualized.
Overall, visibility on the right was less clear than on the
left. This nonvisualization most likely related to technical
factors. If there is concern for a vertebral artery stenosis on
the right (i.e., the patient has symptoms referable to the
posterior circulation of the brain), then a follow-up study or
an alternative study (such as a CTA or MRA) could clarify.
IMPRESSION: Minor wall thickening in the carotid arteries with
no significant carotid stenosis (evaluated as less than 40%
stenosis bilaterally).

Cardiology Report ECHO Study Date of [**2185-9-29**]
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall
left ventricular ejection fraction is preserved (LVEF 60%),
although the
inferior and posterior walls appear hypokinetic. No masses or
thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. There is no mitral valve prolapse. Moderate to severe
(3+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.


CT HEAD W/O CONTRAST  [**2185-10-7**] 9:41 AM
Reason: S/P CABG, NOW UNRESPONSIVE, NEURO CHANGES, EVAL FOR
STROKE, BLEED
FINDINGS: The patient is intubated. There is generalized
cerebral atrophy. There is no intracranial hemorrhage, abnormal
extra-axial fluid collection, mass effect or midline shift. The
ventricles are symmetric, and the cisterns are patent. Minimal
fluid or focal thickening is present in the sphenoid and right
maxillary sinus, possibly related to endotracheal intubation.
IMPRESSION: No intracranial hemorrhage or mass effect.

Cardiology Report ECG Study Date of [**2185-9-28**]  7:47:46 PM
Baseline artifact. Sinus rhythm. Borderline low limb lead
voltage. Marked left
axis deviation consistent with left anterior fascicular block.
Right
bundle-branch block. Probable underlying inferolateral
myocardial infarction.
Non-specific ST-T wave changes consistent with ischemia, etc. No
previous
tracing available for comparison. Clinical correlation is
suggested.

[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 65676**]
FINAL REPORT


INDICATIONS: 84-year-old man with coronary artery disease status
post
coronary artery bypass graft surgery with rising creatinine,
lactate, and
leukocytosis.

COMPARISONS: [**2185-10-28**].

TECHNIQUE: Axial non-contrast CT images of the abdomen and
pelvis were
obtained with oral contrast, and sagittal and coronal
reconstructions were
also performed.

CT OF THE ABDOMEN WITHOUT IV CONTRAST: The lung bases show a few
patchy
ground-glass opacities, which may represent pulmonary venous
congestion. There
is a nasogastric tube in the stomach, and a left-sided chest
tube. There are
smaller, but persistent, bilateral pleural effusions. There is
also a tiny
pneumothorax on the left.

There is new ascites surrounding the liver. The gallbladder is
distended,
with pericholecystic fluid seen. The wall cannot be seen on this
non-contrast
study. The liver is unremarkable. The pancreas, adrenal glands,
and spleen
are within normal limits. There are unchanged bilateral renal
cysts. The left
kidney again demonstrates an atrophic appearance, compared to
the right side.
There is no mesenteric or retroperitoneal lymphadenopathy, or
free air.

The stomach and small bowel are within normal limits. Again
noted is
thickening of the splenic flexure of the colon and descending
colon and
sigmoid. The distribution of the thickening raises possibility
of ischemic
colitis.

CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: Again noted is a
nonobstructing right-sided inguinal hernia. There is a Foley
catheter in the
bladder. The sigmoid demonstrates wall thickening with slight
stranding. The
aorta and iliac vessels are calcified. There is no pelvic or
inguinal
lymphadenopathy.

BONE WINDOWS: Again noted are marked degenerative changes of the
lumbar
spine, but no suspicious lytic or blastic lesions.

IMPRESSION:

1. New gallbladder distention and pericholecystic fluid, as well
as
perihepatic ascites. These findings are suspicious for
acalculous
cholecystitis in this clinical setting, but correlation with
clinical factors
and an ultrasound, if clinically indicated, is advised.

2. Colitis of the descending and sigmoid colon. This
distribution raises the
question of ischemic colitis. Findings were discussed with Dr.
[**Last Name (STitle) 65677**] at
12:20 on [**2185-11-5**].




THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]


Approved: SUN [**2185-11-13**] 12:55 AM
Procedure Date:[**2185-11-5**]

[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier 65676**]
FINAL REPORT


INDICATION: 84-year-old man with mental status changes.
Unresponsive.
Status post CABG.

TECHNIQUE: Non-contrast head CT.

COMPARISON: None.

FINDINGS: The patient is intubated. There is generalized
cerebral atrophy.
There is no intracranial hemorrhage, abnormal extra-axial fluid
collection,
mass effect or midline shift. The ventricles are symmetric, and
the cisterns
are patent. Minimal fluid or focal thickening is present in the
sphenoid and
right maxillary sinus, possibly related to endotracheal
intubation.

IMPRESSION: No intracranial hemorrhage or mass effect.
THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]












Brief Hospital Course:
Mr. [**Known lastname 7280**] was transferred to the [**Hospital1 18**] from an OSH after
undergoing cardiac catheterization which revealed three vessel
disease (90% stenosed LCx, 80% stenosed LAD, 100% occluded RCA,
EF 42%).  Due to the severity of his disease the cardiac surgery
team was consulted for cardiac revascularization.  Upon arrival
at the [**Hospital1 18**] a left groin hematoma was noted on physical exam,
with intact distal pulses.  Initially the patient was stable.
He then became hypotensive with SBP in the 60's.  The patient
was quickly resuscitated with fluid boluses and was transferred
to the CSRU for observation.  The patient was conscious
throughout and EKG's did not show any signs of ischemia.  CT
Abd/Pelvis did not demonstrate any retroperitoneal bleeding.
The patient was then transfused four units of PRBC's.  Pre-op
carotid ultrasound did not show any hemodynamically significant
stenosis.  On hospital day (HOD) 2 the patient was transferred
to the floor while awaiting his MVR/CABG.  He was placed on a
Nitroglycerin drip for coronary vasodilation.  Echo showed LVEF
of 60% and 3+ MR.  His preop urinalysis was suspicious for
infection.  A urine culture was obtained that revealed coagulase
negative staphylococcus sensitive to levaquin.  He was
subsequently placed on Cipro for seven days.  Preoperatively the
patient exhibited some confusion and restlessness.  He was
easily orientable, however on HOD 4 a 1:1 sitter was ordered.
Mr. [**Known lastname 7280**] was usually oriented to person only and required
prompting for further orientation.  On HOD 5 He was given 10mg
Vitamin K x2 doses for an INR of 1.7.

On the morning of HOD 6 Mr. [**Known lastname 65678**] INR was 1.3 and he underwent
CABGx3 (SVG to LAD, SVG to OM1, SVG to OM2) No MVR was
performed.  His left internal mammary artery was found to have
no flow.  Postoperatively he was taken to the cardiac surgery
intensive care unit for monitoring.  On post operative day one
Mr. [**Known lastname 7280**] was very agitated when his propofol was weaned,
however he was hypotensive when sedated.  He was placed on
Haldol for agitiation, and propofol titrated to maintain
sedation without hypotension. CT scan of the head was performed
and did not show any intracranial hemorrhage or mass effect.

Extubated on POD #5 with some postop Afib. Sputum culture showed
MRSA. He was transferred to the floor on POD #7. On POD #10, he
began to complain of abd. tenderness. CT scan of abdomen was
done and general surgery consult obtained. This revealed colonic
thickening with stranding consistent with an ischemic process.
He was kept NPO and remained on abx per gen. [**Doctor First Name **]. Over the next
several days his diet was advanced. On [**10-18**], a PICC line was
placed and on [**10-20**] he was on a full liquid diet.

On [**10-24**], he had some respiratory distress and was transferred
back to the CSRU. Over the next several days, a Swan was
replaced, bronchoscopy was done, TEE done, and a repeat CT of
the abdomen. He required pressors and was reintubated on [**10-26**].
GI consult was obtained, and he concomitantly started CVVHD on
[**10-28**]. Pressure support wean was started, and he was weaned from
his IV pressor support. He was extubated on [**11-3**], and
re-intubated on [**11-4**] for respiratory distress.The following
day, his WBC started to rise significantly and blood cultures
showed VRE. He became somewhat acidotic, and general surgery
performed urgent exploratory laparatomy with cholecystectomy and
GJ tube placement. He was slow to wake from this second general
anesthetic.

On [**11-8**], a permacath was placed for hemodialysis. The following
day, tracheostomy was done and the patient was also taken back
to the OR for bleeding at the trach site.The trach tube was
replaced at that time. He was weaned from pressure support on
the ventilator to trach collar over the next 48 hours and
remains on trach collar now. He appears to respond to commands
appropriately, but is withdrawn and somewhat depressed. On exam
[**11-17**], his belly is soft, BS are coarse, and there is scant
bloody drainage when the trach is suctioned. GJ tube became
obstructed last week and the patient went to interventional
radiology for definitive intervention on the tube on [**11-17**]. Both
tubes are patent, but a Dobhoff tube was placed, and can be
removed once at rehabilitation and patency of g-j tube
confirmed.  (stopped [**11-17**])


Medications on Admission:
Plavix 75mg (stopped [**2185-9-27**])
Benacor 20mg qd
Atenolol 12.5mg qd
Folic acid 1mg qd
flexeril 10mg qd
ultram 50mg qd
mvi qd
methotrexate 6 tabs each week

Discharge Medications:
3. 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*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs one month* Refills:*2*
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs one month* Refills:*2*

1. 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*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs one month* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs one month* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous  Q12H (every 12 hours): thru
[**11-19**].
12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day.
13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous  Q12H (every 12 hours): thru [**11-19**].
14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg
Intravenous  Q24H (every 24 hours): thru [**11-19**].

1. 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*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs one month* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs one month* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous  Q12H (every 12 hours): thru
[**11-19**].
12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day.
13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous  Q12H (every 12 hours): thru [**11-19**].
14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg
Intravenous  Q24H (every 24 hours): thru [**11-19**].

1. 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*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs qs one month* Refills:*2*
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
Disp:*qs qs one month* Refills:*2*
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous  Q12H (every 12 hours): thru
[**11-19**].
12. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day.
13. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred
(600) mg Intravenous  Q12H (every 12 hours): thru [**11-19**].
14. Cefepime 1 g Recon Soln Sig: Five Hundred (500) mg
Intravenous  Q24H (every 24 hours): thru [**11-19**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
CAD
MI approximately 40 years ago
hyperlipidemia
OA
CRI
moderate MR/MVP
mild AI, TR, pulmonary hypertension


Discharge Condition:
good


Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever, redness or drainage from incision, or weight
gain more than 2 pounds in one day or five pounds in one week.
No lifting more than 10 pounds.
No driving until follow up with surgeon.


Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 5017**] in [**11-21**] weeks ([**Telephone/Fax (1) 65679**]
Follow up with Dr. [**Last Name (STitle) **] in [**11-21**] weeks ([**Telephone/Fax (1) 65680**]
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1504**]



Completed by:[**2185-11-18**]
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Urinary tract infection, site not specified,Other tracheostomy complications,Acute cholecystitis,Bacteremia,Unspecified intestinal obstruction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Mitral valve disorders,Atrial fibrillation,Infection with microorganisms resistant to penicillins,Intermediate coronary syndrome'}


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: Worsening shortness of breath with mild to moderate exertion

PRESENT ILLNESS: 84 year old male with history of MVP, moderate MR, mild AI, TR,
mild pulmonary hypertension on recent Echo complaining of
worsening shortness of breath.  He underwent a cardiac
catheterization at [**Hospital6 5016**] that showed three vessel
disease.  He was then transferred to [**Hospital1 18**] for further cardiac
evaluation and referral for cardiac revascularization.

MEDICAL HISTORY: CAD, with +ETT
MI [**19**] years ago
Hyperlipidemia
OA/osteoporosis
Chronic sinusitis
Rheumatoid arthritis
MVP with moderate MR
CRI

MEDICATION ON ADMISSION: Plavix 75mg (stopped [**2185-9-27**])
Benacor 20mg qd
Atenolol 12.5mg qd
Folic acid 1mg qd
flexeril 10mg qd
ultram 50mg qd
mvi qd
methotrexate 6 tabs each week

ALLERGIES: Morphine Sulfate

PHYSICAL EXAM: 84 year old male in NAD status post cardiac catheterization
lying in bed
HEENT- PERRL
CVS- S1/S2 no m/r/g
Pulm- B/S CTA
ABD-S/NT/ND
Vascular- no carotid bruits, varicosities.  Left groin hematoma
with distal pulses present, groin hematoma expanding on
admission

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives at home with wife, denies alcohol or tobacco use (quit 40
years ago) 

### Response:
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure with lesion of tubular necrosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hematoma complicating a procedure,Urinary tract infection, site not specified,Other tracheostomy complications,Acute cholecystitis,Bacteremia,Unspecified intestinal obstruction,Methicillin susceptible pneumonia due to Staphylococcus aureus,Mitral valve disorders,Atrial fibrillation,Infection with microorganisms resistant to penicillins,Intermediate coronary syndrome'}
