CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 56898**] is a 79 year old male with history of hypertension,
hyperlipidemia, paroxysmal Afib, and PVD who was sent to ED by
his nephrologist as she noticed he was SOB with O2 sat 84% on RA
with pursed lip breathing. Recently admitted to [**Hospital1 18**] [**Date range (1) 56899**]
with NSTEMI which was medically managed (on asa, metoprolol,
simvastatin, and nitro) [**2-25**] to acute on chronic RF.  He was
d/c'ed to rehab and since had been living with his daughter.  [**Name (NI) **]
states that his SOB started about 1-2 weeks ago and has been
progressing such that he is now SOB at rest. He also notes
increased swelling of LE bilat. Denies
CP/palpitations/nausea/dizziness. No cough/abd pain. No f/c/ns.
He claims that he has been compliant with medications and that
he cannot swallow foods (for months) so drinks high energy
shakes.

MEDICAL HISTORY: 1. CAD??silent MI in the past
2. COPD
3. paroxysmal Afib
4. hypercholesterolemia
5. bilateral CEA about 20y ago
6. PVD s/p angioplasty LLE about 10y ago
7. neck CA s/p XRT 7y ago

MEDICATION ON ADMISSION: Toprol
Colace
Sennokot
MVI
Zocor
Prevacid
Trazodone
Iron
Combivent
Procrit
Dulcolax
Allopurinol
Nephrocaps
Amiodarone
Plavix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.5, BP 90-110/50-60, P68, 94% on RA
Gen-very pleasant elderly  gentleman, comfortable lying in bed,
in no
pain/distress, +NC on 6L O2
HEENT-anicteric, oral mucosa dry, OP- pink/dry - no lesions;
neck supple JVD + 10cm
CVS-HS - distant, rrr, no murmur
resp: CTA with bibasilar crackles
ABD: soft, nt/nd, +BS
ext-2+ pitting edema to knees bilat.; no c/c; spont movt of all
4 ext.

FAMILY HISTORY: MI in father at 65yo

SOCIAL HISTORY: denies tobacco/ETOH
Congestive heart failure, unspecified,Atrial fibrillation,Cardiogenic shock,Chronic airway obstruction, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acute respiratory failure,Hyperpotassemia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcal septicemia,Severe sepsis,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Peripheral vascular disease, unspecified,Pure hypercholesterolemia,Iron deficiency anemia, unspecified,Personal history of malignant neoplasm of other sites
CHF NOS,Atrial fibrillation,Cardiogenic shock,Chr airway obstruct NEC,Ac DVT/emb distl low ext,Acute respiratry failure,Hyperpotassemia,Thrombocytopenia NOS,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Streptococcal septicemia,Severe sepsis,Crnry athrscl natve vssl,Subendo infarct, subseq,Periph vascular dis NOS,Pure hypercholesterolem,Iron defic anemia NOS,Hx of malignancy NEC
Admission Date:  [**2178-1-26**]              Discharge Date:   [**2178-2-5**]

Date of Birth:  [**2098-2-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 7539**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization x 3 with PCI stenting
Intubation
Intra-aortic balloon pump placement

History of Present Illness:
Mr. [**Known lastname 56898**] is a 79 year old male with history of hypertension,
hyperlipidemia, paroxysmal Afib, and PVD who was sent to ED by
his nephrologist as she noticed he was SOB with O2 sat 84% on RA
with pursed lip breathing. Recently admitted to [**Hospital1 18**] [**Date range (1) 56899**]
with NSTEMI which was medically managed (on asa, metoprolol,
simvastatin, and nitro) [**2-25**] to acute on chronic RF.  He was
d/c'ed to rehab and since had been living with his daughter.  [**Name (NI) **]
states that his SOB started about 1-2 weeks ago and has been
progressing such that he is now SOB at rest. He also notes
increased swelling of LE bilat. Denies
CP/palpitations/nausea/dizziness. No cough/abd pain. No f/c/ns.
He claims that he has been compliant with medications and that
he cannot swallow foods (for months) so drinks high energy
shakes.

Was sent by ambulance from clinic. Oxygen saturation was 100% on
NRB on arrival, and 98% on 2L via NC. Pt given 80 IV lasix in ED
with much symptomatic improvement. I/O even in ED b/c was
maintained on IVF from ambulance. (I/O=500cc/500cc)

Past Medical History:
1. CAD??silent MI in the past
2. COPD
3. paroxysmal Afib
4. hypercholesterolemia
5. bilateral CEA about 20y ago
6. PVD s/p angioplasty LLE about 10y ago
7. neck CA s/p XRT 7y ago

Social History:
denies tobacco/ETOH

Family History:
MI in father at 65yo

Physical Exam:
T 97.5, BP 90-110/50-60, P68, 94% on RA
Gen-very pleasant elderly  gentleman, comfortable lying in bed,
in no
pain/distress, +NC on 6L O2
HEENT-anicteric, oral mucosa dry, OP- pink/dry - no lesions;
neck supple JVD + 10cm
CVS-HS - distant, rrr, no murmur
resp: CTA with bibasilar crackles
ABD: soft, nt/nd, +BS
ext-2+ pitting edema to knees bilat.; no c/c; spont movt of all
4 ext.

neuro-A+Ox3, move all 4 limbs symmetrically, no facial
asymmetry; CN 2-12 grossly intact; 5/5 strength of
biceps/tricps/knee flex/ext. sensation to light touch intact
throughout.

Pertinent Results:
[**2178-1-26**] WBC-5.2 RBC-4.41* Hgb-12.0* Hct-38.2* MCV-87 MCH-27.3
MCHC-31.5 RDW-17.3* Plt Ct-229
[**2178-2-5**] WBC-5.3 RBC-3.10* Hgb-8.3* Hct-26.0* MCV-84 MCH-26.7*
MCHC-31.8 RDW-18.0* Plt Ct-37*
[**2178-1-26**] Neuts-73.3* Bands-0 Lymphs-20.9 Monos-5.3 Eos-0.1
Baso-0.3
[**2178-2-1**] Neuts-74.4* Bands-0 Lymphs-19.3 Monos-5.6 Eos-0.3
Baso-0.4

[**2178-1-27**] PT-13.4 PTT-30.4 INR(PT)-1.1
[**2178-2-5**] Plt Ct-37*
[**2178-2-2**] Fibrino-357
[**2178-2-5**] Fibrino-546*#
[**2178-2-5**] FDP-10-40

[**2178-1-26**] Glucose-91 UreaN-54* Creat-2.5*# Na-135 K-4.7 Cl-103
HCO3-24
[**2178-2-5**] Glucose-116* UreaN-52* Creat-3.2* Na-136 K-3.3 Cl-99
HCO3-27
[**2178-1-26**] 05:00PM BLOOD CK(CPK)-65  cTropnT-0.02*
[**2178-1-27**] 06:58AM BLOOD CK(CPK)-44  cTropnT-0.04*
[**2178-1-29**] 05:35AM BLOOD CK(CPK)-26*  CK-MB-4 cTropnT-0.03*
[**2178-2-3**] 10:37PM BLOOD CK(CPK)-683*  CK-MB-11* MB Indx-1.6
[**2178-2-4**] 10:06PM BLOOD CK(CPK)-788*  CK-MB-66* MB Indx-8.4*

[**2178-1-28**] ALT-18 AST-15 AlkPhos-69 Amylase-45 TotBili-0.5
[**2178-2-1**] ALT-36 AST-90* LD(LDH)-697* CK(CPK)-130 AlkPhos-99
TotBili-0.6
[**2178-2-2**] 02:55AM BLOOD LD(LDH)-311* CK(CPK)-60 TotBili-0.5
DirBili-0.2 IndBili-0.3
[**2178-2-5**] 09:30AM BLOOD LD(LDH)-847*

[**2178-1-28**] Calcium-8.2* Phos-3.8 Mg-1.9 [**2178-2-1**] Albumin-3.1*
Calcium-8.4 Phos-3.8 Mg-1.9

[**2178-1-28**] Iron-32* calTIBC-286 Ferritn-36 TRF-220
[**2178-2-2**] Hapto-132

[**2178-1-28**] PTH-102*

[**2178-2-5**] 04:22PM BLOOD Cortsol-37.3*

[**2178-2-5**] HEPARIN DEPENDENT ANTIBODIES        NEGATIVE

CXR [**2178-1-26**]:
1) Interval development of moderate sized bilateral pleural
effusions with associated atelectatic changes.
2) Mild interstitial edema.

EKG [**2178-1-26**]:  Sinus rhythm. Borderline P-R interval prolongation.
Low limb lead voltage. Late R wave progression. ST-T wave
abnormality. Since the previous tracing of [**2177-12-11**] sinus rhythm
is now present and the Q-T interval is longer.

Cardiac Cath [**2178-1-28**]:
COMMENTS:     1.  Selective coronary angiography revealed a
right-dominant system.  The LMCA had an ostial 95% lesion.  The
LAD had diffuse irregularities with a 90% mid D2 lesion.
The LCx had sequential 80% mid-vessel lesions.
The RCA had sequential 90% mid-vessel lesions.
2.  The left and right-sided filling pressures were both
moderately
elevated (RA mean 10mmHg, RVEDP 10mmHg, PA mean 31mmHg, PCWP
mean
21mmHg).  The estimated cardiac output was 3.81 l/min.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.

Carotid Duplex [**2178-1-30**]:  Inhomogenous mostly Isoechoic plaque
involving the carotid arteries bilaterally with post- surgical
changes and intimal hyperplasia. This represents moderaltely
severe (60-69%) stenosis on the right and less than 40%
hemodynamic effect on the left.

RLE US [**2178-1-31**]:  IMPRESSION: Nonocclussive right common femoral
deep venous thrombosis.

EKG [**2178-1-31**]:  Probable atrial fibrillation with a rapid
ventricular response. Since the previous tracing of [**2178-1-27**]
atrial fibrillation is new. ST-T wave abnormalities may be more
prominent.

CXR [**2178-2-1**]:  1) Interval improvement in bilateral pleural
effusions, most dramatically on the left.
2) Left apical linear density most likely representing a skin
fold. Repeat imaging is recommended for further evaluation.
3) Nasogastric tube withdrawals within the body of stomach, and
tip is ascending to the level of the gastroesophageal junction.

Cardiac Cath [**2178-2-1**]:
COMMENTS:
1. Selective coronary arteriography of this right dominant
system
revealed 3 vessel coronary artery disease. The LMCA had a 99%
ostial
lesion. The LAD had moderate diffuse disease with a 80% distal
lesion as
well as a 80% lesion in the D1. The LCX had a 80% lesion. The
RCA was
heavily calcified with diffuse disease throughout its course and
a 80%
mid and 90% distal lesion.
2. Hemodynamic evaluation revealed marked elevation of the right
and
left sided filling pressures with a RA of 10mmHg and mean PCWP
of 38mmHg
with significant "V" waves. There was evidence of moderate
pulmonary HTM
with a PAP of 50/32mmHg. The calculated cardiac index by Fick
using a O2
consumption of 125 ml/min revealed a cardiac index of 4.8
Lt/min/M2 on
100% FiO2 and 20 mcg/kg/min of Dopamine.
3. Distal aortography revealed a totally occlusive 8F 40CC IABP
in the
right common iliac artery. The LCIA had seral 80% lesions at to
the
LCFA. The LSFA was totally occluded and reconstituted via
collaterals at
the level of te adductor cannal.
4. Successful PTCA/stenting of the LMCA with a 3.0x13mm Cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 7930**] with a 3.5x13mm balloon. Final angiography revealed
no
residual stenosis, no dissection and TIMI-3 flow (see PTCA
comments).
5. Successful Atherectomy, stenting of the Left CIA/CFA with a
9.0x56mm
and a 8.0x80mm Danalik sefl expandable stents. Final angiography

revealed no residual stenosis, no dissection and TIMI-3 flow
(see PTCA
comments).
6. Successful removal of a 8F 40cc IABP from the right common
femoral
artery resulting in restoration of arterial flow.
7. Successful placement of a 8F 40cc IABP in the left common
femoral
artery.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated right and left heart filling pressure.
3. Pulmonary HTN.
4. Peripheral vascular disease.
5. PCI of the LMCA.
6. PCI of the left CIA/CFA.
7. IABP placement.

Transthoracic echo [**2178-2-2**]:
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate global left
ventricular hypokinesis (EF ~30%) that becomes severely
depressed (<20%) with the IABP off. The right ventricular free
wall is hypertrophied. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No definite aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild [1+] mitral
regurgitation is seen with the IABP "off" with trivial mitral
regurgitation with the IABP "on." There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. There
are prominent bilateral pleural effusions.

Cardiac cath [**2178-2-3**]:
COMMENTS:
1. Limited coronary angiography demonstrated a right dominant
system
with no significant disease in the recently placed LMCA stent as
well as
severe diffuse calcified 90% disease in the proximal and
mid-RCA.
2. Limited resting hemodynamics revealed mean arterial pressure
of 82
mmHg on a previously placed IABP via the left femoral artery as
well as
neosynephrine.
3. Successful placement of five overlapping stents in the RCA.
The sizes
from the ostium listed to the distal vessel included 3.0 x 18 mm
Zeta,
3.0 x 38 mm Zeta, 2.5 x 28 mm Pixel, 2.5 x 28 mm Pixel, and 2.5
x 28 mm
Pixel. Final angiography demonstrated no residual stenosis, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
4. Successful placement of 7.0 x 40 mm Absolute self-expanding
stent in
right iliac artery postdilated with a 6.0 mm balloon. Final
angiography
demonstrated minimal residual stenosis, no angiographically
apparent
dissection, and normal flow (See PTCA Comments).

FINAL DIAGNOSIS:
1. Planned intervention of single vessel coronary artery
disease.
2. Cardiogenic shock on IABP and pressores with MAP 82 mmHg.
3. Successful placement of 5 stents in RCA.
4. Successful placement of self-expanding stent in right iliac
artery.

CXR [**2178-2-4**]:  1) Interval dramatic improvement in bilateral
pulmonary edema. Moderate right sided and small left-sided
pleural effusions persist.

EKG [**2178-2-5**]:  Sinus rhythm. Low limb lead voltage. S1, S2, S3
pattern. Persistent S wave to lead V6. ST-T wave abnormalities.
Probable Q-T interval prolongation. The Q-T interval is
difficult to calculate due to low voltage, artifact and probable
positive U waves. Since the previous tracing of [**2178-2-4**] the Q-T
interval prolongation is more apparent but probably was present
and less appreciated in the previous tracing.

MICRO:
URINE CULTURE (Final [**2178-1-27**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    10,000-100,000
ORGANISMS/ML..

AEROBIC BOTTLE (Final [**2178-2-8**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2178-2-8**]):    NO GROWTH.

URINE CULTURE (Final [**2178-2-3**]):    NO GROWTH.

BLOOD AEROBIC BOTTLE (Final [**2178-2-5**]):
      REPORTED BY PHONE TO [**First Name9 (NamePattern2) 56900**] [**Doctor Last Name **] @ 0318 ON [**2178-2-3**].
      ENTEROCOCCUS FAECALIS.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
         gentamicin. Screen predicts possible synergy with
selected
         penicillins or vancomycin. Consult ID for details.
         HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
         streptomycin.  Screen predicts possible synergy with
selected
         penicillins or vancomycin.  Consult ID for details..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS FAECALIS
                             |
AMPICILLIN------------   <=2 S
LEVOFLOXACIN----------   0.5 S
PENICILLIN------------     4 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC BOTTLE (Final [**2178-2-8**]):    NO GROWTH.

AEROBIC BOTTLE (Final [**2178-2-9**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2178-2-9**]):    NO GROWTH.

SPUTUM GRAM STAIN (Final [**2178-2-5**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Final [**2178-2-10**]):
      MODERATE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         OF TWO COLONIAL MORPHOLOGIES.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    MODERATE
GROWTH.
      GRAM NEGATIVE ROD #2.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
                             |          |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------     4 I
OXACILLIN-------------<=0.25 S
PENICILLIN------------ =>0.5 R
TRIMETHOPRIM/SULFA----             <=20 S


Brief Hospital Course:
A/P: Mr. [**Known lastname 56898**] was a 79 yo gentleman with h/o hypertension,
hyperlipidemia, PAfib
PVD, CRI, and recent NSTEMI, who presented from PCP with CHF
exacerbation.

1. CHF exacerbation: The patient was thought to be having a CHF
exacerbation of unclear etiology.  On admission, he was put on
1.5L fluid restriction and started on lasix, 40mg IV BID, to
which he responded well with symptomatic improvement. Lasix was
stopped on [**1-28**] for cardiac cath (performed secondary to concern
that his symptoms were related to cardiac ischemia) and because
BP remained low with SBP in 80's-100 range.  Cardiac cath was
done on [**1-28**] with results as in pertinent results section -
significant 3 vessel disease with a severe L main lesion. Given
these results, it was thought unlikely that Mr. [**Known lastname 56901**] CHF
would improve without further intervention, ie CABG. However,
given his pulmonary/renal status, there was much discussion as
to whether Mr. [**Known lastname 56898**] was surgical candidate.

He had one episode of shortness of breath on the night of [**1-31**]
which responded to lasix and rate control, as he was noted to be
in atrial fibrillation.  The following night, however he had an
episode of dyspnea unresponsive to lasix.  His SBP was 130s, HR
70s in NSR.  He eventually required a 100% NRB.  An ABG showed
hypoxia at 7.41/39/63, and he was intubated and transferred to
the CCU where an intra-aortic balloon pump was placed at the
bedside, and he was placed on pressors for hypotension, presumed
secondary to cardiogenic shock.

Upon review of his catheterization report, it was felt that the
patient's recurrent SOB and acute pulmonary edema was likely
related to ischemia, and it was decided to take the patient to
the cath lab for a second time, for stenting of his left main
coronary artery.  During cath he underwent stenting of the LMCA
with a 3.0 x 13 mm Cypher drug-eluting stent as well as stenting
of the left iliac artery and common femoral artery with 9.0 x 56
mm, 8.0 x 80 mm, and 8.0 x 56 mm Dynalink stents all postdilated
with a 8.0 mm balloon.

Unfortunately, post-cath his hemodynamic status did not improve,
and he was highly dependent on the balloon pump, and unable to
be extubated.  It was decided that as one last effort, the
patient would have planned intervention of the heavily calcified
RCA with planned rotational atherectomy, which he underwent on
[**2178-2-3**] with placement of 5 stents in the RCA.

After this catheterization the patient was weaned off the
balloon pump, however remained on levophed for blood pressure
support.  His urine output was poor, therefore nesiritide was
attempted however this caused him to become hypotensive.  It was
felt that there may have been a component of septic shock as
well, with 1 bottle positive for enterococcus on [**2-4**].  He was
started on ampicillin.

Unfortunately, the patient's poor hemodynamic status, combined
with his acute on chronic renal failure (likely secondary to
poor perfusion secondary to CHF and hypotension as well as
multiple die loads and resultant ATN), a dopping platelet count,
poor oxygenation, and enterococcal blood infection, all proved
to be too much for him, and he was pronounced dead on [**2178-2-5**] at
6:27 p.m.  The patient was not on anticoagulation at the time
secondary to concerns for HIT, and it is also possible that he
had a pulmonary embolus, as he had non-occlussive thrombus in
his right common femoral deep venous system on [**1-31**].

2. CAD: As above.  We continued his simvastatin, asa,
lisinopril, and metoprolol.

3. Atrial fibrillation:  He had a history of paroxysmal atrial
fibrillation, and had been on coumadin in the past, however this
had been discontinued during a previous admission for a GI
bleed.  He was controlled on amiodarone and metoprolol, but did
flip in and out of atrial fibrillation during his
hospitalization.

4. Acute on chronic renal failure: Followed by Dr. [**Last Name (STitle) 1860**] as an
outpatient; creatinine 2.5 on admission, however rose to 3.6 on
[**2-4**] after his second catheterization, likely a combination of
poor perfusion as well as ATN from multiple contrast loads.

5. Enterococcal bacteremia:  As above, the patient was found to
have 1 blood culture bottle positive for enterococcus from [**2-2**].
 He was started on ampicillin, however was only 2 days into
treatment when he died.

6. Thrombocytopenia:  His platelets were noted to be trending
down on [**2-1**] just after his second catheterization and balloon
pump placement.  His platelets nadired at 37 on the day of his
death.  PT and PTT were both mildly elevated as well, however
fibrinogen was within normal limits.  HIT antibody was negative.
 Nevertheless, all heparin products were discontinued, and his
balloon pump was removed as it was heparin coated.  It is
unclear what caused his thrombocytopenia.  It could still have
been HIT despite the negative antibody test.

Medications on Admission:
Toprol
Colace
Sennokot
MVI
Zocor
Prevacid
Trazodone
Iron
Combivent
Procrit
Dulcolax
Allopurinol
Nephrocaps
Amiodarone
Plavix

Discharge Medications:
Patient deceased.

Discharge Disposition:
Expired

Discharge Diagnosis:
Congestive Heart Failure
Coronary artery disease
Cardiogenic shock
Thrombocytopenia
Enterococcal bacteremia
Acute on chronic renal failure

Discharge Condition:
Deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A
{'Congestive heart failure, unspecified,Atrial fibrillation,Cardiogenic shock,Chronic airway obstruction, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acute respiratory failure,Hyperpotassemia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcal septicemia,Severe sepsis,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Peripheral vascular disease, unspecified,Pure hypercholesterolemia,Iron deficiency anemia, unspecified,Personal history of malignant neoplasm of other sites'}


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: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 56898**] is a 79 year old male with history of hypertension,
hyperlipidemia, paroxysmal Afib, and PVD who was sent to ED by
his nephrologist as she noticed he was SOB with O2 sat 84% on RA
with pursed lip breathing. Recently admitted to [**Hospital1 18**] [**Date range (1) 56899**]
with NSTEMI which was medically managed (on asa, metoprolol,
simvastatin, and nitro) [**2-25**] to acute on chronic RF.  He was
d/c'ed to rehab and since had been living with his daughter.  [**Name (NI) **]
states that his SOB started about 1-2 weeks ago and has been
progressing such that he is now SOB at rest. He also notes
increased swelling of LE bilat. Denies
CP/palpitations/nausea/dizziness. No cough/abd pain. No f/c/ns.
He claims that he has been compliant with medications and that
he cannot swallow foods (for months) so drinks high energy
shakes.

MEDICAL HISTORY: 1. CAD??silent MI in the past
2. COPD
3. paroxysmal Afib
4. hypercholesterolemia
5. bilateral CEA about 20y ago
6. PVD s/p angioplasty LLE about 10y ago
7. neck CA s/p XRT 7y ago

MEDICATION ON ADMISSION: Toprol
Colace
Sennokot
MVI
Zocor
Prevacid
Trazodone
Iron
Combivent
Procrit
Dulcolax
Allopurinol
Nephrocaps
Amiodarone
Plavix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 97.5, BP 90-110/50-60, P68, 94% on RA
Gen-very pleasant elderly  gentleman, comfortable lying in bed,
in no
pain/distress, +NC on 6L O2
HEENT-anicteric, oral mucosa dry, OP- pink/dry - no lesions;
neck supple JVD + 10cm
CVS-HS - distant, rrr, no murmur
resp: CTA with bibasilar crackles
ABD: soft, nt/nd, +BS
ext-2+ pitting edema to knees bilat.; no c/c; spont movt of all
4 ext.

FAMILY HISTORY: MI in father at 65yo

SOCIAL HISTORY: denies tobacco/ETOH 

### Response:
{'Congestive heart failure, unspecified,Atrial fibrillation,Cardiogenic shock,Chronic airway obstruction, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Acute respiratory failure,Hyperpotassemia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Streptococcal septicemia,Severe sepsis,Coronary atherosclerosis of native coronary artery,Subendocardial infarction, subsequent episode of care,Peripheral vascular disease, unspecified,Pure hypercholesterolemia,Iron deficiency anemia, unspecified,Personal history of malignant neoplasm of other sites'}
