CHIEF COMPLAINT: Dyspnea.

PRESENT ILLNESS: Mr [**Known lastname **] is a 71-year-old man with a PMHx significant for
systolic HF (EF 20-25%), old anterior wall MI, paroxysmal AV
block, atrial fibrillation, ventricular tachycardia, history of
ventricular fibrillation in the past, status post eventual BiV
ICD implantation with subsequent revisions due to the presence
of malfunctioning Fidelis lead, who presented to the ED this
morning with a chief complaint of dyspnea. The patient reports
that he began having a cough productive of dark beige sputum for
the past week. He also had some low-grade temps at home (Tm
99.8) earlier this week. He called his cardiologist on [**2141-2-28**],
complaining of this cough and LE edema. He was told to increase
his lasix to 60mg TIW and 40 mg daily the rest of the week. He
then presented to gerontology clinic on [**2141-3-1**] with similar
complaints. CXR and CBC done that day were unremarkable. He then
developed dyspnea over the past 24-36 hours. He called
cardiology clinic this morning and was instructed to present to
the ED.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
- Anterior wall myocardial infarction in [**2126**] with ventricular
tachycardia and complete heart block requiring pacemaker
- Systolic heart failure (EF 20-25%)
- Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Anemia.
4. Irritable bowel syndrome.
5. Constipation.
6. Obesity.
7. Hearing loss, requiring bilateral hearing aids.
8. Squamous cell carcinoma of the left lower eyelid.
9. Vitamin D deficiency.
10. Cerebral infarct.
11. Falls.
12. Compression fractures.
13. History of Whipple operation, with subsequent E. coli and
Klebsiella bacteremia
14. History of possible C3-C4 osteomyelitis
15. Abdominal hernia secondary to Whipple procedure
PAST SURGICAL HISTORY:
1. Placement of pacemaker and ICD.
2. Knee surgery.
3. Removal of squamous cell carcinoma of his left lower eyelid.

MEDICATION ON ADMISSION: AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth Tues/[**Last Name (un) **]/Sat/Sun and 1.2 tabs (60mg) on
M/W/F
LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day
LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth 3x/day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day
NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth [**2-23**]

ALLERGIES: Penicillins / Ambien

PHYSICAL EXAM: Admission Exam:
VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP
GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple. Unable to appreciate JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

FAMILY HISTORY: Strong family history of vascular disease with father deceased
of CVA at 59, Mother with MI at 70, Brother with MI and CABG in
50's. Also reports a family history of diabetes.

SOCIAL HISTORY: Teaches history at [**University/College 15559**]. Divorced, 2 children.
Lives in [**Location **], but is staying intermittently in [**Location (un) **] with his
[**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Former pipe and cigarette smoker (quit
>10 years ago).  Used to smoke 1ppd X 30 yrs. Drinks [**12-24**] glasses
of wine/day. No drugs. Health Care Proxy: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac arrest,Mechanical complication due to cardiac pacemaker (electrode),Anoxic brain damage,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Other abnormal glucose,Hypotension, unspecified,Dysphagia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Anemia, unspecified,Irritable bowel syndrome,Obesity, unspecified,Unspecified hearing loss,Unspecified vitamin D deficiency,Ventral, unspecified, hernia without mention of obstruction or gangrene,Long-term (current) use of antibiotics,Personal history of other malignant neoplasm of skin,Other postprocedural status
Ac on chr syst hrt fail,Acute respiratry failure,Pneumonia, organism NOS,Cardiac arrest,Malfunc cardiac pacemake,Anoxic brain damage,Prim cardiomyopathy NEC,Hyperosmolality,Other alter consciousnes,Crnry athrscl natve vssl,Old myocardial infarct,Hypertension NOS,Abnormal glucose NEC,Hypotension NOS,Dysphagia NOS,Abn react-artif implant,Hypothyroidism NOS,Anemia NOS,Irritable bowel syndrome,Obesity NOS,Hearing loss NOS,Vitamin D deficiency NOS,Ventral hernia NOS,Long-term use antibiotic,Hx-skin malignancy NEC,Post-proc states NEC
Admission Date:  [**2141-3-3**]              Discharge Date:   [**2141-3-31**]

Date of Birth:  [**2069-2-9**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Ambien

Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Dyspnea.

Major Surgical or Invasive Procedure:
Endotracheal Intubation
Transesophageal Echocardiogram


History of Present Illness:
  Mr [**Known lastname **] is a 71-year-old man with a PMHx significant for
systolic HF (EF 20-25%), old anterior wall MI, paroxysmal AV
block, atrial fibrillation, ventricular tachycardia, history of
ventricular fibrillation in the past, status post eventual BiV
ICD implantation with subsequent revisions due to the presence
of malfunctioning Fidelis lead, who presented to the ED this
morning with a chief complaint of dyspnea. The patient reports
that he began having a cough productive of dark beige sputum for
the past week. He also had some low-grade temps at home (Tm
99.8) earlier this week. He called his cardiologist on [**2141-2-28**],
complaining of this cough and LE edema. He was told to increase
his lasix to 60mg TIW and 40 mg daily the rest of the week. He
then presented to gerontology clinic on [**2141-3-1**] with similar
complaints. CXR and CBC done that day were unremarkable. He then
developed dyspnea over the past 24-36 hours. He called
cardiology clinic this morning and was instructed to present to
the ED.

  On arrival to the ED, the patient's VS were 97.1 80 100/60 22
96. He was noted to have crackles half-way up bilaterally. CXR
reportedly showed changes c/w pulmonary edema as well as a ? LLL
opacification. In the ED, he received Levofloxacin 750mg,
Vancomycin 1g, Ondansetron 4mg, and Furosemide 40mg. He was
admitted to the CCU for further management.

  On arrival to the CCU, the patient's VS were T= 98.7 BP=
103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP. He reported that his
dyspnea was improved. He stated that the chest pressure that he
experienced earlier had resolved. He endorses recent worsening
DOE and PND. He also reports some chest pressure last night and
this morning, which was located across his chest, did not
radiate, and has since resolved. He reports recent 5-pound
weight gain. He also reports recent loose stools and stable
urinary frequency.

  On review of systems, he denied any prior history of stroke.
He did report a questionable history of TIA. He denied any
history of deep venous thrombosis, pulmonary embolism, bleeding
at the time of surgery, myalgias, joint pains, hemoptysis, black
stools or red stools. He denied recent chills or rigors. He
denied exertional buttock or calf pain. All of the other review
of systems were negative.

  Cardiac review of systems is notable for absence of
palpitations or syncope.

Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
- Anterior wall myocardial infarction in [**2126**] with ventricular
tachycardia and complete heart block requiring pacemaker
- Systolic heart failure (EF 20-25%)
- Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Anemia.
4. Irritable bowel syndrome.
5. Constipation.
6. Obesity.
7. Hearing loss, requiring bilateral hearing aids.
8. Squamous cell carcinoma of the left lower eyelid.
9. Vitamin D deficiency.
10. Cerebral infarct.
11. Falls.
12. Compression fractures.
13. History of Whipple operation, with subsequent E. coli and
Klebsiella bacteremia
14. History of possible C3-C4 osteomyelitis
15. Abdominal hernia secondary to Whipple procedure
PAST SURGICAL HISTORY:
1. Placement of pacemaker and ICD.
2. Knee surgery.
3. Removal of squamous cell carcinoma of his left lower eyelid.

4. Recent Whipple's procedure for which he was diagnosed with
dysplasia.

Social History:
Teaches history at [**University/College 15559**]. Divorced, 2 children.
Lives in [**Location **], but is staying intermittently in [**Location (un) **] with his
[**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Former pipe and cigarette smoker (quit
>10 years ago).  Used to smoke 1ppd X 30 yrs. Drinks [**12-24**] glasses
of wine/day. No drugs. Health Care Proxy: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]


Family History:
Strong family history of vascular disease with father deceased
of CVA at 59, Mother with MI at 70, Brother with MI and CABG in
50's. Also reports a family history of diabetes.

Physical Exam:
Admission Exam:
VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP
GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple. Unable to appreciate JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

LUNGS: Resp were unlabored, no accessory muscle use. Pt with
high-flow neb O2 mask on. Crackles noted [**12-24**] to [**2-23**] of the way
up bilaterally. Scattered wheezes as well.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness noted. Ventral
hernia present.
EXTREMITIES: No significant LE edema noted. No calf pain. DP
pulses palpable bilaterally.


Pertinent Results:
Admission Labs
[**2141-3-3**] 10:15AM BLOOD WBC-7.1 RBC-3.71* Hgb-11.9* Hct-35.3*
MCV-95# MCH-32.0 MCHC-33.7 RDW-14.4 Plt Ct-166
[**2141-3-3**] 10:15AM BLOOD Neuts-78.8* Lymphs-13.5* Monos-5.0
Eos-2.3 Baso-0.5
[**2141-3-3**] 10:15AM BLOOD PT-24.2* PTT-33.2 INR(PT)-2.3*
[**2141-3-3**] 10:15AM BLOOD Glucose-152* UreaN-28* Creat-1.1 Na-135
K-4.4 Cl-99 HCO3-25 AnGap-15
[**2141-3-3**] 10:15AM BLOOD ALT-27 AST-36 CK(CPK)-126 AlkPhos-139*
TotBili-0.6
[**2141-3-3**] 10:15AM BLOOD Lipase-64*
[**2141-3-3**] 10:15AM BLOOD cTropnT-<0.01
[**2141-3-3**] 10:15AM BLOOD CK-MB-4 proBNP-3057*
[**2141-3-3**] 10:15AM BLOOD Albumin-4.1
[**2141-3-3**] 10:25AM BLOOD Lactate-2.0
[**2141-3-3**] 11:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2141-3-3**] 11:10AM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2141-3-3**] 11:10AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2

CXR ([**2141-3-3**]) - IMPRESSION: Increased pulmonary edema.
Superimposed infectious process in
the left lower lobe cannot be excluded. Recommend follow-up post
diuresis.

CT Chest ([**2141-3-7**]) - IMPRESSION:
1. No intrathoracic abscess. Bilateral non-hemorrhagic
small-to-moderate pleural effusions, minimally loculated, if at
all, on the right.
2. Severe lower lobe and moderate upper lobe atelectasis.
Minimal pneumonia cannot be excluded.
3. Mediastinal lymphadenopathy, likely reactive.

CT Head ([**2141-3-11**]) - IMPRESSION: No evidence of infectious or
other acute process.

CT Abd/Pelvis ([**2141-3-11**]) - IMPRESSION:
1. No evidence of infectious process in the abdomen or pelvis.
2. Ground-glass opacity in lung bases may partially be explained
by fluid overload, although an infectious component should be
considered.
3. Slightly increased bilateral small pleural effusions with
associated atelectasis.
4. Unchanged postoperative findings related to prior Whipple and
hepatojejunostomy, with soft tissue in the postoperative bed,
which appears stable, of unclear significance.
5. Apparently new rectus muscle herniation containing
non-obstructed bowel.
6. Unchanged compression fracture of L1.

TEE ([**2141-3-14**]) - No atrial septal defect is seen by 2D or color
Doppler. There is moderate to severe regional left ventricular
systolic dysfunction with septal, inferoseptal and inferior
hypokinesis. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. No mass or vegetation is seen on the
mitral valve. Moderate to severe (3+) mitral regurgitation is
seen. Moderate to severe [2+] tricuspid regurgitation is seen.
There is at least mild pulmonary artery systolic hypertension.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No vegetations seen on the pacemaker/ICD leads (at
least 4 wires identified in the right atrium) or on the valves.
Depressed left ventricular systolic function. Moderate to severe
mitral regurgitation. At least mild pulmonary hypertension.
Complex atheroma in descending aorta.

Brief Hospital Course:
  71 y/o M with PMHx significant for systolic HF (EF 20-25%), MI
in '[**26**], paroxysmal AV block, atrial fibrillation, h/o v.tach and
v.fib s/p ICD implantation, who presented to the ED this morning
with a chief complaint of dyspnea, likely due to CHF
exacerbation.

Respiratory Failure
  Pt's respiratory distress initially was thought to be related
to CHF exacerbation in the setting of possible dietary
indiscretion. He was given IV lasix initially with good urine
output. However, later on the evening of admission, he became
febrile and CXR was c/w possible PNA. Pt was started on
vanc/cefepime and was continued on azithromycin (started in ED)
as broad coverage for a possible PNA. On the following evening
([**2141-3-4**]), pt had worsening respiratory status and was
intubated. Thus, respiratory failure was attributed to both
decompensated congestive heart failure as well as pneumonia.
Despite being on broad spectrum abx, the patient continued to
spike fevers, and his abx were eventually switched to meropenem
monotherapy (see below). Bronch was performed but did not reveal
an obvious infective process. With diuresis and abx therapy,
pt's respiratory status improved. He was ultimately extubated on
[**2141-3-14**].  He was subsequently re-intubated for pacemaker
procedure on [**2141-3-23**] and extubated the following day on [**2141-3-24**].
He did not have any respiratory comlpications following this.

Fevers
  As above, the patient began to spike fevers on the evening of
admission. At that time, he was started on
vanc/cefepime/azithromycin as broad coverage for a suspected
PNA. When he continued to spike fevers on this regimen, viral
screens were sent and his antibiotic regimen was changed to
meropenem. ID was consulted, as the patient has a complex
medical history involving chronic cefpodoxime for ongoing
suppression after high-grade viridans streptococcal bacteremia
as well as suspected Klebsiella pneumoniae ICD/pacer lead
endocarditis during a prior bacteremia. The patient's pacer was
interrogated, and it was found that his ICD was not functioning
properly. Despite recurrent fevers, even when he was on
meropenem, the patient did not have any positive culture data,
aside from yeast in the sputum and one positive blood culture
(which was a likely contaminant). TEE was performed and did not
show any evidence of vegetation. The patient's fevers ultimately
subsided. With no positive culture data to guide therapy, his
antibiotics were d/c'ed and he was placed back on his chronic
cefpodoxime regimen per his infectious disease physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 3197**] whom he will follow up with this month.

ICD Malfunction
  As explained above, the patient's pacer was interrogated early
in his hospital course, and it was noted to not be working
properly. On the afternoon of [**2141-3-12**], he went into to VT and
was unable to be paced out of it by his pacer. He then went into
VF arrest, and his ICD did not shock him out of it.
Consequently, he received approximately 2 minutes of CPR and 1
external defibrillation with return of a perfusing rhythm. On
the morning of [**2141-3-17**], the patient had an additional episode of
VF, for which he required external defibrillation and CPR. After
this, his pacer was set at a higher rate to avoid fast-slow-fast
sequences that may have precipitated the episode of ventricular
tachycardia. Throughout all of this, the patient was followed by
the EP service. Plans were made to take the patient to the OR
for possible removal and replacement of his leads. The patient's
dose of amiodarone was also briefly increased in an attempt to
prevent episodes of VT; his metoprolol was also increased.  On
[**2141-3-23**] the patient underwent two lead extractions (R ventricular
and R atrial) and ICD implant without complications.  He was
extubated the following day.  He was discharged with increased
doses with amiodarone and metoprolol.

Altered mental status
  Patient exhibited aggitation consistent with ICU delerium
post-intubation.  He was pan cultured, but did not have evidence
of infection.  It was thought that he may have also sufferred
anoxic brain injury during his multiple v fib arrest/v tach.
However, over a few days his mental status dramatically
improved.  He then went for his ICD lead revision and following
extubation became acutely aggitated again.  He received ativan
.5 mg IV x 2, which worsened his delerium.  Small doses of
haldol and zydis were tried, but did not have good effect
either.  The patient was started on seroquel standing dose at
night plus PRNs and he had drastic improvement in his mental
status.  His paxil was also weaned down to 20 mg a day and
should continue to be weaned off slowly over the next few weeks.
 He is being discharged on 6.26 mg seroquel Q HS.  He required
one extra PRN dose the night before discharge and was slightly
disoriented the morning of discharge.  However, overall his
mental status has improved dramatically, and this is likely the
result of his prolonged ICU stay.  All labs have remained normal
and there are no signs of infection or metabolic abnormalities.

Coronary Artery Disease
  Pt with a history of an anterior wall MI in [**2126**]. Of note, the
patient did report some chest pressure prior to admission.
However, on arrival to the CCU, he denied any chest pain. He
ruled out for ACS with three sets of CE's. He was continued on
metoprolol and aspirin.

Atrial Fibrillation
  Pt with a history of a.fib, for which he takes coumadin. In
anticipation for possible procedures regarding his ICD, the
patient was taken off of coumadin and placed on a heparin gtt in
the meantime.  He was restarted on coumadin 3 mg once a day and
his INR was elevated to 3.4.  His coumadin was subsequently
decreased to 2 mg a day.  His INR will need to be checked daily
and his coumadin adjusted as needed for a goal [**1-25**].  He may
require a lower dose still given he is now on amiodarone which
can interact with INR.

Hypotension
  Normotensive on presentation. On pressors (levophed) for a
short time after he was intubated. After he was weaned off of
pressors, his beta blocker was able to be restarted.  On [**3-27**] -
[**3-28**] he was noted to have hypotension to the 70's systolic when
sitting/standing up.  This was thought to be due to poor PO
intake and volume contraction.  The patient continued to mentate
well despite the hypotension.  He was given IV fluid boluses
with response in his blood pressure.  As he continues to improve
his PO intake this is expected to resolve.  He should continue
to have holding parameters on his beta blocker to prevent
hypotension in the meantime.  He was not ressztarted on an ACE
inhibitor due to the low blood pressures.  This may be restarted
at a later date by his PCP/cardiologist if his blood pressures
will tolerate it.

Congestive Heart Failure
  As stated above the patient will continue on his regimen of
aspirin and metoprolol with holding parameters.  His ACEi was
held as stated above due to hypotension and may be restarted at
low dose (2.5 mg) in the future as blood pressure tolerates it.

Nutrition and Dysphagia
  The patient was on tube feeds while he was intubated and
sedated.  Following each intubation he had profound aggitation
and delerium.  He failed his swallow studies several times and
had to have a dobhoff tube placed.  Due to his aggitation he
self-removed his dobhoff tube and his nutrition was interrupted
several times.  On day 5 following his intubation, discussions
were held whether he should have a bridled NGT placed versus a
PEG tube.  It was decided that he would get a PEG tube as this
was thought to be less disturbing to the patient versus a long
term bridled NGT that he might try to pull out, and it would
only be temporary until his dysphagia improved.  However, that
morning he passed his swallow study.  He was restarted on a
pureed diet with nectar thick liquids.  It is anticipated that
his swallow function will continue to improve during rehab.

Increased CK
  Pt was noted to have elevated CK, peaking at 2723. CK-MB and
troponin were unremarkable. His statin was held, and his CK's
were trended. They continued to improve.

Hypothyroidism
  The patient's levothyroxine was continued at 50 mcg daily.

Anemia
  Pt with a history of anemia, baseline Hct of approx. 33-35. Pt
currently near his baseline.  He was continued on iron
supplementation.

S/p Whipple
  Was continued initially on pancreatic enzyme repletion, which
were stopped when the patient was on tube feeds.  These were
restarted when he was able to take PO again.

CODE: FULL CODE, confirmed with patient and his HCP
[**Name (NI) **]: HCP is [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 15561**])

Medications on Admission:
AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth Tues/[**Last Name (un) **]/Sat/Sun and 1.2 tabs (60mg) on
M/W/F
LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day
LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth 3x/day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day
NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth [**2-23**]

times/day swish in mouth and swallow
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg
Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth
DAILY
PAROXETINE HCL [PAXIL] - 30 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
SIMVASTATIN [ZOCOR] - 20 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Start
with 1/2 pill. [**Month (only) 116**] increase to 1 pill if needed; may increase to
total of 2 pills as needed
WARFARIN - 1 mg Tablet - 1 (One)-3 Tablet(s) by mouth as
directed by MD
ACETAMINOPHEN - (OTC) - Dosage uncertain
ASCORBIC ACID - (Prescribed by Other Provider) - 250 mg Tablet -
1 Tablet(s) by mouth daily
ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81
mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth
once a day
FERROUS SULFATE [SLOW FE] - 142 mg (45 mg Iron) Tablet Sustained
Release - 1 (One) Tablet(s) by mouth every other day
LACTOBACILLUS ACIDOPHILUS [ACIDOPHILUS] - (OTC) - Dosage
uncertain
MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet
- 1 (One) Tablet(s) by mouth once a day


Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pancrease MT 10 10,000-30,000 -30,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
TIDAC.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Ascorbic Acid 250 mg Tablet Sig: One (1) Tablet PO once a
day.
11. Slow Fe 142 mg (45 mg Iron) Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO once a day.
12. Lactobacillus Acidophilus  Miscellaneous
13. Multiple Vitamins     Tablet Sig: One (1) Tablet PO once a
day.
14. Quetiapine 25 mg Tablet Sig: 0.25 Tablet PO at bedtime.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary
- Acute on Chronic Heart Failure
- Ventricular Fibrillation / Cardiac Arrest
- Hospital acquired pneumonia
- Delerium

Secondary:
- coronary artery disease
- hyperthyroidism


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the ICU with worsening of your heart
failure. Soon after admission, your respiratory status worsened,
and you were intubated. It was felt that you might also have a
pneumonia, so you were started on antibiotics. Additionally,
while you were in the hospital, you had 2 episodes of abnormal
heart rhythms for which you required CPR and electrical shocks.
Your internal defibrillator was interrogated and was felt to not
be functioning properly so it was replaced.  You also developed
some delerium in the ICU and had trouble swallowing food.  Your
mental status is now improving and you are able to take pureed
food.

CHANGES TO YOUR MEDICATIONS:
**Increase amiodarone to 200 mg once a day
**Increase metoprolol to 25 mg once a day
**Decrease Paxil to 20 mg once a day
**Decrease coumadin to 2 mg a day
**Stop lasix
**Stop simvastatin
**Stop trazodone

Please weigh yourself every morning and call your doctor if you
weight goes up more than 3 lbs.

Followup Instructions:
Please follow-up with:

Cardiology:
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-4-13**] 3:00

Infectious disease:
Provider: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD
Date/Time:[**2141-4-4**] 2:00

Primary care provider:
[**Name10 (NameIs) 357**] call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to schedule
a follow up appointment after you leave rehab.  The phone number
is: [**Telephone/Fax (1) 719**]
{'Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac arrest,Mechanical complication due to cardiac pacemaker (electrode),Anoxic brain damage,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Other abnormal glucose,Hypotension, unspecified,Dysphagia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Anemia, unspecified,Irritable bowel syndrome,Obesity, unspecified,Unspecified hearing loss,Unspecified vitamin D deficiency,Ventral, unspecified, hernia without mention of obstruction or gangrene,Long-term (current) use of antibiotics,Personal history of other malignant neoplasm of skin,Other postprocedural status'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Dyspnea.

PRESENT ILLNESS: Mr [**Known lastname **] is a 71-year-old man with a PMHx significant for
systolic HF (EF 20-25%), old anterior wall MI, paroxysmal AV
block, atrial fibrillation, ventricular tachycardia, history of
ventricular fibrillation in the past, status post eventual BiV
ICD implantation with subsequent revisions due to the presence
of malfunctioning Fidelis lead, who presented to the ED this
morning with a chief complaint of dyspnea. The patient reports
that he began having a cough productive of dark beige sputum for
the past week. He also had some low-grade temps at home (Tm
99.8) earlier this week. He called his cardiologist on [**2141-2-28**],
complaining of this cough and LE edema. He was told to increase
his lasix to 60mg TIW and 40 mg daily the rest of the week. He
then presented to gerontology clinic on [**2141-3-1**] with similar
complaints. CXR and CBC done that day were unremarkable. He then
developed dyspnea over the past 24-36 hours. He called
cardiology clinic this morning and was instructed to present to
the ED.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Hypertension
2. CARDIAC HISTORY:
- Anterior wall myocardial infarction in [**2126**] with ventricular
tachycardia and complete heart block requiring pacemaker
- Systolic heart failure (EF 20-25%)
- Atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Anemia.
4. Irritable bowel syndrome.
5. Constipation.
6. Obesity.
7. Hearing loss, requiring bilateral hearing aids.
8. Squamous cell carcinoma of the left lower eyelid.
9. Vitamin D deficiency.
10. Cerebral infarct.
11. Falls.
12. Compression fractures.
13. History of Whipple operation, with subsequent E. coli and
Klebsiella bacteremia
14. History of possible C3-C4 osteomyelitis
15. Abdominal hernia secondary to Whipple procedure
PAST SURGICAL HISTORY:
1. Placement of pacemaker and ICD.
2. Knee surgery.
3. Removal of squamous cell carcinoma of his left lower eyelid.

MEDICATION ON ADMISSION: AMIODARONE - 200 mg Tablet - 0.5 (One half) Tablet(s) by mouth
once a day
CEFPODOXIME - 100 mg Tablet - 2 Tablet(s) by mouth twice daily
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth Tues/[**Last Name (un) **]/Sat/Sun and 1.2 tabs (60mg) on
M/W/F
LEVOTHYROXINE [LEVOXYL] - 50 mcg Tablet - 1 (One) Tablet(s) by
mouth once a day
LIPASE-PROTEASE-AMYLASE [PANCREASE MT 10] - 30,000 unit-[**Unit Number **],000
unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth 3x/day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth once a day
NYSTATIN - 100,000 unit/mL Suspension - 1 (One) tsp by mouth [**2-23**]

ALLERGIES: Penicillins / Ambien

PHYSICAL EXAM: Admission Exam:
VS: T= 98.7 BP= 103/67 HR= 76 RR= 21 O2 sat= 97% on BiPAP
GENERAL: Alert, NAD. Oriented x3. Mood, affect appropriate.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple. Unable to appreciate JVP.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

FAMILY HISTORY: Strong family history of vascular disease with father deceased
of CVA at 59, Mother with MI at 70, Brother with MI and CABG in
50's. Also reports a family history of diabetes.

SOCIAL HISTORY: Teaches history at [**University/College 15559**]. Divorced, 2 children.
Lives in [**Location **], but is staying intermittently in [**Location (un) **] with his
[**Last Name (LF) 15560**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Former pipe and cigarette smoker (quit
>10 years ago).  Used to smoke 1ppd X 30 yrs. Drinks [**12-24**] glasses
of wine/day. No drugs. Health Care Proxy: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 

### Response:
{'Acute on chronic systolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Cardiac arrest,Mechanical complication due to cardiac pacemaker (electrode),Anoxic brain damage,Other primary cardiomyopathies,Hyperosmolality and/or hypernatremia,Other alteration of consciousness,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Unspecified essential hypertension,Other abnormal glucose,Hypotension, unspecified,Dysphagia, unspecified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Unspecified acquired hypothyroidism,Anemia, unspecified,Irritable bowel syndrome,Obesity, unspecified,Unspecified hearing loss,Unspecified vitamin D deficiency,Ventral, unspecified, hernia without mention of obstruction or gangrene,Long-term (current) use of antibiotics,Personal history of other malignant neoplasm of skin,Other postprocedural status'}
