CHIEF COMPLAINT: weakness and syncope

PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 yo man with a  history of CAD, nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD, DM,
recent admission for decompensated CHF, who is transferred from
[**Hospital3 **] for initial complaint of weakness and
subsequent VT storm.
.
This afternoon, the patient reported sudden onset of
lightheadedness followed by a fall, striking his head but
without LOC.  He called EMS.  On transfer to the stretcher, his
AICD fired.  It subsequently fired 4 more times within 30
minutes.  He was initially taken to an OSH and thought to be in
a paced rhythm.  It fired a fifth time there, at which time he
was started on an amiodarone bolus of 150mg IV and started on a
1mg/min gtt.  He was later given a second amiodarone bolus of
150mg IV.  OSH Labs notable for hyponatremia to 122 and
hypokalemia to 3.1.  He received K 40mEq po, Mg 2gm IV.  He also
received morphine 4mg IV, ativan 1mg IV x 2, and 1 inch of nitro
paste, then transferred to our ED.
.
On ED arrival, VS were: P 105, 116/82, RR 20, O2sat 92% on RA.
EKG showed a wide paced rhythm.  He had a transient episode of
VF with a sixth firing, then conversion back to sinus.  He was
given K 40mEq po and 40mEq IV and continued on the amiodarone
gtt.  Interrogation of his ICD confirmed the 6 firings today as
well as an additional firing each on [**1-21**] and [**1-23**] which the
patient did not recall.  He also has increasingly been ATP paced
out of VT/VF since the end of [**Month (only) **]/beginning of [**Month (only) 1096**].
BNP 5317.  His CXR showed fluid overload.  Lasix 120mg IV was
given with UOP of 350 cc within an hour.  A NCHCT was done given
his fall on coumadin; no acute intracranial findings were seen.
VS on transfer: P 96, BP 94/69, RR 23, O2sat 98 on 3LNC.
.
Of note, the patient was recently admitted to our CCU from
[**Date range (1) 87244**] after undergoing coronary angiography at LGH and
being found to have a tight RCA lesion and occlusion of a large
OM.  The cath was complicated by hemodynamic instability and
acute pulmonary edema requiring transfer here.  Echo showed
severe global hypokinesis with regional variation and mild AS.
He was in afib and VT during his hospital course and was shocked
by his defibrillator multiple times, so he underwent AV nodal
ablation followed by a BiV pacer upgrade. He also underwent
successful rotablation of the large RCA with IABP support
intraop; attempt to open the OM was unsuccessful.  His
hemodynamics improved and patient was aggressively diuresed with
improvement in his CHF.  He was initially discharged on
torsemide, but since his discharge from rehab, he has been on
lasix 160mg [**Hospital1 **], which he felt has been more efficacious.  He
denies any dyspnea on exertion; no orthopnea (1-pillow), PND,
edema.  He saw his cardiologist 1 week ago, at which time he was
noted to be hypokalemic.  He was started on potassium 60mEq [**Hospital1 **]
although as noted above, K was low on presentation.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.

MEDICAL HISTORY: CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.
-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceridemia
Chronic systolic CHF
Afib on coumadin
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]

MEDICATION ON ADMISSION: Metolazone 2.5mg Q Wed AM (was holding)
Amiodarone 200mg daily
Metoprolol succinate 12.5mg daily
Lisinopril 5mg daily
Lasix 160mg [**Hospital1 **]
Potassium 60mEq [**Hospital1 **]
Gemfibrozil 600mg [**Hospital1 **]
Lipitor 40mg qhs
Niaspan 500mg qhs
Aspirin 325mg daily
Plavix 75mg daily
Coumadin 5mg as directed
Famotidine 20mg [**Hospital1 **]
Novolog 2 units qAC sliding scale
Lantus 10 units qhs
Vitamin D [**2172**] units qAM
Multivitamin daily

ALLERGIES: Penicillins / Actos / Percocet / Cephalosporins

PHYSICAL EXAM: On Admission
VS: T=96.2 BP=140/83 HR=93 RR=25 O2 sat=97% 3L NC
GENERAL: Somewhat chronically ill-appearing Caucasian male
appearing uncomfortable. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Former smoker
-ETOH: no etoh
Is not married. Lives alone and was driving prior to admission.
Has an elderly aunt and uncle who try to help him at home but pt
has been very frustrated with them. Does not appear to have any
other family. Has been compliant with therapy
Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Hypopotassemia,Unspecified hereditary and idiopathic peripheral neuropathy,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin
Parox ventric tachycard,Acute kidney failure NOS,Ac on chr syst hrt fail,Prim cardiomyopathy NEC,Hypopotassemia,Idio periph neurpthy NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Status autm crd dfbrltr,Long-term use of insulin
Admission Date:  [**2183-1-24**]              Discharge Date:   [**2183-1-30**]

Date of Birth:  [**2122-3-3**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Actos / Percocet / Cephalosporins

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
weakness and syncope

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname **] is a 60 yo man with a  history of CAD, nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD, DM,
recent admission for decompensated CHF, who is transferred from
[**Hospital3 **] for initial complaint of weakness and
subsequent VT storm.
.
This afternoon, the patient reported sudden onset of
lightheadedness followed by a fall, striking his head but
without LOC.  He called EMS.  On transfer to the stretcher, his
AICD fired.  It subsequently fired 4 more times within 30
minutes.  He was initially taken to an OSH and thought to be in
a paced rhythm.  It fired a fifth time there, at which time he
was started on an amiodarone bolus of 150mg IV and started on a
1mg/min gtt.  He was later given a second amiodarone bolus of
150mg IV.  OSH Labs notable for hyponatremia to 122 and
hypokalemia to 3.1.  He received K 40mEq po, Mg 2gm IV.  He also
received morphine 4mg IV, ativan 1mg IV x 2, and 1 inch of nitro
paste, then transferred to our ED.
.
On ED arrival, VS were: P 105, 116/82, RR 20, O2sat 92% on RA.
EKG showed a wide paced rhythm.  He had a transient episode of
VF with a sixth firing, then conversion back to sinus.  He was
given K 40mEq po and 40mEq IV and continued on the amiodarone
gtt.  Interrogation of his ICD confirmed the 6 firings today as
well as an additional firing each on [**1-21**] and [**1-23**] which the
patient did not recall.  He also has increasingly been ATP paced
out of VT/VF since the end of [**Month (only) **]/beginning of [**Month (only) 1096**].
BNP 5317.  His CXR showed fluid overload.  Lasix 120mg IV was
given with UOP of 350 cc within an hour.  A NCHCT was done given
his fall on coumadin; no acute intracranial findings were seen.
VS on transfer: P 96, BP 94/69, RR 23, O2sat 98 on 3LNC.
.
Of note, the patient was recently admitted to our CCU from
[**Date range (1) 87244**] after undergoing coronary angiography at LGH and
being found to have a tight RCA lesion and occlusion of a large
OM.  The cath was complicated by hemodynamic instability and
acute pulmonary edema requiring transfer here.  Echo showed
severe global hypokinesis with regional variation and mild AS.
He was in afib and VT during his hospital course and was shocked
by his defibrillator multiple times, so he underwent AV nodal
ablation followed by a BiV pacer upgrade. He also underwent
successful rotablation of the large RCA with IABP support
intraop; attempt to open the OM was unsuccessful.  His
hemodynamics improved and patient was aggressively diuresed with
improvement in his CHF.  He was initially discharged on
torsemide, but since his discharge from rehab, he has been on
lasix 160mg [**Hospital1 **], which he felt has been more efficacious.  He
denies any dyspnea on exertion; no orthopnea (1-pillow), PND,
edema.  He saw his cardiologist 1 week ago, at which time he was
noted to be hypokalemic.  He was started on potassium 60mEq [**Hospital1 **]
although as noted above, K was low on presentation.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.


Past Medical History:
CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.
-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceridemia
Chronic systolic CHF
Afib on coumadin
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]


Social History:
-Tobacco history: Former smoker
-ETOH: no etoh
Is not married. Lives alone and was driving prior to admission.
Has an elderly aunt and uncle who try to help him at home but pt
has been very frustrated with them. Does not appear to have any
other family. Has been compliant with therapy

Family History:
Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
On Admission
VS: T=96.2 BP=140/83 HR=93 RR=25 O2 sat=97% 3L NC
GENERAL: Somewhat chronically ill-appearing Caucasian male
appearing uncomfortable. Oriented x3. Mood, affect appropriate.

HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP at level of tragus
CARDIAC: Very difficult auscultation. IIR, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: Diffuse wet crackles to apices b/l
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 1+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 1+
.
At discharge:
GENERAL: NAD. Oriented x3. Fatigued.
HEENT: MM dry
NECK: Supple with JVD 1/3 up
CARDIAC: normal S1, S2. 2/6 Systolic murmur.  No thrills, lifts.
No S3 or S4.
LUNGS: BB crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema. Stasis changes in LE.
PULSES:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+


Pertinent Results:
Admission:
[**2183-1-24**] 08:15AM BLOOD WBC-10.2 RBC-3.97* Hgb-12.3* Hct-36.8*
MCV-93 MCH-31.0 MCHC-33.5 RDW-15.3 Plt Ct-268
[**2183-1-24**] 01:46AM BLOOD Neuts-90.0* Lymphs-6.5* Monos-3.2 Eos-0.1
Baso-0.2
[**2183-1-24**] 01:46AM BLOOD PT-24.2* PTT-29.7 INR(PT)-2.3*
[**2183-1-24**] 01:46AM BLOOD Glucose-241* UreaN-43* Creat-1.5* Na-123*
K-3.3 Cl-81* HCO3-28 AnGap-17
[**2183-1-24**] 01:46AM BLOOD ALT-22 AST-34 CK(CPK)-119 AlkPhos-98
TotBili-0.5
[**2183-1-24**] 01:46AM BLOOD CK-MB-6 proBNP-5317*
[**2183-1-24**] 01:46AM BLOOD cTropnT-<0.01
[**2183-1-24**] 01:46AM BLOOD Albumin-4.6 Calcium-9.1 Phos-3.8 Mg-2.7*
.
Discharge:
[**2183-1-30**] 07:05AM BLOOD WBC-9.6 RBC-3.91* Hgb-12.0* Hct-35.0*
MCV-90 MCH-30.7 MCHC-34.2 RDW-15.9* Plt Ct-184
[**2183-1-30**] 07:05AM BLOOD PT-69.9* PTT-37.9* INR(PT)-8.1*
[**2183-1-30**] 07:05AM BLOOD Glucose-100 UreaN-95* Creat-2.3* Na-122*
K-4.1 Cl-80* HCO3-29 AnGap-17
[**2183-1-30**] 07:05AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.
=============================Imaging======================
Head CT:
FINDINGS: No acute hemorrhage, edema, mass effect or evidence of
recent
infarction is seen. Prominence of the ventricles and sulci
reflects a mild
degree of generalized atrophy. Incidental note is made of a
cavum septum
pellucidum. No concerning osseous lesion or fracture is
identified. The
visualized paranasal sinuses are grossly unremarkable. There are

calcifications of the bilateral carotid siphons.
.
IMPRESSION: Motion degraded study; however, no evidence of acute
intracranial process seen.
.
CXR:
FINDINGS: The heart is enlarged with new pleural effusions,
right greater
than left. Mild pulmonary edema and vascular congestion are new.
No
pneumothorax is seen. A left-sided pacemaker appears in
unchanged position
though evaluation of the leads is limited due to overlying
wires.

IMPRESSION: Recurrent congestive heart failure.


Brief Hospital Course:
60yo M w/ CAD, CHF with an EF of 16% s/p ICD w/ recent upgrade
to BiV, DM, AF on coumadin transferred from OSH after
unwitnessed fall at home, now s/p multiple shocks related to VT
storm.
.
# Ventricular Tachycardia: Hypokalemic on admission. On transfer
to [**Hospital1 18**] interrogation of his ICD confirmed the 6 firings on the
day of admission as well as an one firing on [**1-21**] and [**1-23**]
which the patient did not recall. Also noted that he has been
ATP paced out of VT/VF for the past 2 months. On admission, he
was demand paced. Likely entered VT in the setting of
hypokalemia with known arryhtmogenic substrate given cardiac
history. He was loaded with amiodarone and his home metoprolol
succinate dose was increased to 25mg daily. He was seen by
electrophysiology team who considered ablation but has deferred
at this time. Mexilitine was added and pt had no more VT
episodes during hospital stay. Warfarin dose was at 4-5 mg daily
but was held on [**2183-1-29**] for supratherapeutic INR. INR cont to
rise and on [**1-30**] was 8.1. Vitamin K 2mg x1 given on [**1-30**] and
INR should be checked daily with resumption of warfarin when INR
< 3.0.
.
# CAD: admitted in decompensated CHF and no s/s of ACS. Home
aspirin and plavix were continued, statin and fibrate continued
with niacin held given non-formulary. Cardiac enzymes flat.
Titrated metoprolol up to 25mg succinate daily. His aspirin was
decreased to 81 mg.
.
# Acute on Chronic Systolic Congestive Heart Failure: On
admission, patient was noted to be in acute systolic CHF. Last
EF 16%. Chest films showed pulmonary edema, BNP was 5317, and he
appeared clinically volume overloaded on exam. CHF exacerbation
was related to myocardial stunning in setting of multiple ICD
firings. He had been on Metolozone at home but this was being
held. He was treated initially with IV furosemide and then
transitioned to furosemide PO. On day of discharge, his weight
was 100kg and he appeared mildly fluid overloaded with 1+
peripheral edema and bibasilar crackles. Furosemide was
increased to 80 mg [**Hospital1 **] (home dose 160 mg [**Hospital1 **]) and aldactone was
continued. Please follow fluid status, daily weights closely and
titrate diuretics. Fluid restriction is at 1500cc/day.
Lisinopril 5 mg was held because of renal dysfunction. Would
restart at 2.5 once creatinine < 2.0.
.
# Hyponatremia: Na range 120-127 during hospital stay. Initially
thought [**3-12**] fluid overload but did not normalize witih diuresis.
Urine lytes were difficult to interpret in setting of diuresis
and shifting fluid volumes, could be SIADH. Pt is asymptomatic.
Needs lytes daily until stable.
.
# Head injury: patient reported that he had fallen and struck
the left side of his face. Given that he was on coumadin, a non
contrast head CT scan was performed which showed no acute
intracranial findings. His mental status is alert, oriented x
[**2-9**] but he is discouraged about health status and sometimes
seems disoriented. No focal neuro findings.
.
# Acute on Chronic Kidney Injury: Creat range 1.5-2.3 during
hospital stay, now 2.3, thought [**3-12**] vigorous diuresis and CHF.
We have renally dosed medicines and Lisinopril was held.
Lisinopril should be restarted when creat < 2.0 at 2.5 mg daily.

.
# DM: Lantus increased to 15 units at hs, gave ISS while
inpatient. Please see attached sliding scale humalog
.
# Dispo: Pt. lives alone, concern for ability to care for self,
unable to drive at this time [**3-12**] VT. SW involved and should have
consult on admission. He has an elderly aunt and uncle who try
to help him but he struggles to take care of his home/bills and
health at home. He will need maximum supports at home.

Medications on Admission:
Metolazone 2.5mg Q Wed AM (was holding)
Amiodarone 200mg daily
Metoprolol succinate 12.5mg daily
Lisinopril 5mg daily
Lasix 160mg [**Hospital1 **]
Potassium 60mEq [**Hospital1 **]
Gemfibrozil 600mg [**Hospital1 **]
Lipitor 40mg qhs
Niaspan 500mg qhs
Aspirin 325mg daily
Plavix 75mg daily
Coumadin 5mg as directed
Famotidine 20mg [**Hospital1 **]
Novolog 2 units qAC sliding scale
Lantus 10 units qhs
Vitamin D [**2172**] units qAM
Multivitamin daily


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
hold SBP < 95.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Five (5)
Tablet PO DAILY (Daily).
9. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
14. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous three times a day: check FS before meals.
15. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
17. Niaspan Extended-Release 500 mg Tablet Sustained Release
Sig: One (1) Tablet Sustained Release PO at bedtime.
18. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Acute on chronic systolic congestive heart failure
Ventricular Tachycardia s/p ICD shocks
Coronary artery disease
Diabetes mellitus type 2.
Atrial fibrillation
Hyponatremia
Acute on Chronic Kidney Injury


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You had ventricular tachycardia and was shocked by the ICD. Your
amiodarone was increased and a new medicine called mexilitine
was started to prevent the ventricular tachycardia. If you have
any more ventricular tachycaria, you will probably have an
ablation scheduled by Dr. [**Last Name (STitle) **]. Please call Dr. [**Last Name (STitle) **]
right away if the ICD fires. You cannot drive until Dr.
[**Last Name (STitle) **] says that it is OK. Weigh yourself every morning, call
Dr. [**First Name (STitle) 437**] if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days.
.
Medication changes:
1. Stop taking your Lisinopril because of your kidney function.
This will be restarted when your kidney function improves
2. Increase Metoprolol to 25 mg daily
3. Increase Amiodarone to 200 mg [**Hospital1 **]
4. Start taking Mexililtine to prevent the ventricular
tachycardia
5. Start Spironolactone to help decrease fluid retention
6. Stop taking potassium supplements on a daily basis. Your labs
will be checked frequently and potassium will be given as needed
7. Decrease furosemide to 80 mg twice daily
8. Stop taking Lisinopril until your kidney function improves.
9. Stop taking Metolazone
10. Decrease your aspirin to 81 mg daily
11. Stop taking coumadin for now, your INR will be checked
daily.


Followup Instructions:
Please call Dr. [**Last Name (STitle) 63252**] when you get out of rehabilitation to
make an appt.

Department: CARDIAC SERVICES
When: MONDAY [**2183-2-10**] at 3:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2183-3-12**] at 1:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2183-1-30**]
{'Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Hypopotassemia,Unspecified hereditary and idiopathic peripheral neuropathy,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin'}


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: weakness and syncope

PRESENT ILLNESS: Mr. [**Known lastname **] is a 60 yo man with a  history of CAD, nonischemic
cardiomyopathy with an ejection fraction of 20% and ICD, DM,
recent admission for decompensated CHF, who is transferred from
[**Hospital3 **] for initial complaint of weakness and
subsequent VT storm.
.
This afternoon, the patient reported sudden onset of
lightheadedness followed by a fall, striking his head but
without LOC.  He called EMS.  On transfer to the stretcher, his
AICD fired.  It subsequently fired 4 more times within 30
minutes.  He was initially taken to an OSH and thought to be in
a paced rhythm.  It fired a fifth time there, at which time he
was started on an amiodarone bolus of 150mg IV and started on a
1mg/min gtt.  He was later given a second amiodarone bolus of
150mg IV.  OSH Labs notable for hyponatremia to 122 and
hypokalemia to 3.1.  He received K 40mEq po, Mg 2gm IV.  He also
received morphine 4mg IV, ativan 1mg IV x 2, and 1 inch of nitro
paste, then transferred to our ED.
.
On ED arrival, VS were: P 105, 116/82, RR 20, O2sat 92% on RA.
EKG showed a wide paced rhythm.  He had a transient episode of
VF with a sixth firing, then conversion back to sinus.  He was
given K 40mEq po and 40mEq IV and continued on the amiodarone
gtt.  Interrogation of his ICD confirmed the 6 firings today as
well as an additional firing each on [**1-21**] and [**1-23**] which the
patient did not recall.  He also has increasingly been ATP paced
out of VT/VF since the end of [**Month (only) **]/beginning of [**Month (only) 1096**].
BNP 5317.  His CXR showed fluid overload.  Lasix 120mg IV was
given with UOP of 350 cc within an hour.  A NCHCT was done given
his fall on coumadin; no acute intracranial findings were seen.
VS on transfer: P 96, BP 94/69, RR 23, O2sat 98 on 3LNC.
.
Of note, the patient was recently admitted to our CCU from
[**Date range (1) 87244**] after undergoing coronary angiography at LGH and
being found to have a tight RCA lesion and occlusion of a large
OM.  The cath was complicated by hemodynamic instability and
acute pulmonary edema requiring transfer here.  Echo showed
severe global hypokinesis with regional variation and mild AS.
He was in afib and VT during his hospital course and was shocked
by his defibrillator multiple times, so he underwent AV nodal
ablation followed by a BiV pacer upgrade. He also underwent
successful rotablation of the large RCA with IABP support
intraop; attempt to open the OM was unsuccessful.  His
hemodynamics improved and patient was aggressively diuresed with
improvement in his CHF.  He was initially discharged on
torsemide, but since his discharge from rehab, he has been on
lasix 160mg [**Hospital1 **], which he felt has been more efficacious.  He
denies any dyspnea on exertion; no orthopnea (1-pillow), PND,
edema.  He saw his cardiologist 1 week ago, at which time he was
noted to be hypokalemic.  He was started on potassium 60mEq [**Hospital1 **]
although as noted above, K was low on presentation.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations.

MEDICAL HISTORY: CARDIAC HISTORY: Positive for non-ischemic cardiomyopathy with
ejection fraction 16%.
-PACING/ICD: VVI AICD implated on [**2180-4-26**]
3. OTHER PAST MEDICAL HISTORY:
Diabetes type II on insulin
Hypercholesterolemia
Peripheral neuropahty
Hypertriglyceridemia
Chronic systolic CHF
Afib on coumadin
Dilated non-ischemic cardiomyopathy
Multinodule goitor likely due to amiodarone
Past surgical history:
Appy
Chole
Epigastric hernia repair
Tonsillectomy
AICD/pacemaker implanted [**2180-4-8**]

MEDICATION ON ADMISSION: Metolazone 2.5mg Q Wed AM (was holding)
Amiodarone 200mg daily
Metoprolol succinate 12.5mg daily
Lisinopril 5mg daily
Lasix 160mg [**Hospital1 **]
Potassium 60mEq [**Hospital1 **]
Gemfibrozil 600mg [**Hospital1 **]
Lipitor 40mg qhs
Niaspan 500mg qhs
Aspirin 325mg daily
Plavix 75mg daily
Coumadin 5mg as directed
Famotidine 20mg [**Hospital1 **]
Novolog 2 units qAC sliding scale
Lantus 10 units qhs
Vitamin D [**2172**] units qAM
Multivitamin daily

ALLERGIES: Penicillins / Actos / Percocet / Cephalosporins

PHYSICAL EXAM: On Admission
VS: T=96.2 BP=140/83 HR=93 RR=25 O2 sat=97% 3L NC
GENERAL: Somewhat chronically ill-appearing Caucasian male
appearing uncomfortable. Oriented x3. Mood, affect appropriate.

FAMILY HISTORY: Father died with rectal cancer
Mother has [**Name2 (NI) **] of colon ca, rheumatic valvular dz
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Former smoker
-ETOH: no etoh
Is not married. Lives alone and was driving prior to admission.
Has an elderly aunt and uncle who try to help him at home but pt
has been very frustrated with them. Does not appear to have any
other family. Has been compliant with therapy 

### Response:
{'Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Hypopotassemia,Unspecified hereditary and idiopathic peripheral neuropathy,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Automatic implantable cardiac defibrillator in situ,Long-term (current) use of insulin'}
