CHIEF COMPLAINT: Malaise, shortness of breath

PRESENT ILLNESS: Patient is a 72 y.o. Male w/ h.o. CAD s/p CABG [**2148**] w/ redo in
[**2163**] (has LIMA->LAD, SVG->LAD, SVG->OM in [**2148**], redo included
SVG-> PDA, SVG to prior LIMA), multiple stents (LMCA, D1 in
[**2160**]; PCI to SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]),
DM II, HL who presents as a transfer from OSH w/ NSTEMI.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+),
Hypertension (-)
2. CARDIAC HISTORY:
AVF ([**10/2163**])
-CABG:  [**2163**], [**2148**] (LIMA-LAD, SVG LAD, SVG OM)
-PERCUTANEOUS CORONARY INTERVENTIONS:  LMCA, D1 in [**2160**]; PCI to
SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]
   -Cath [**10/2162**]: Three vessel native coronary artery disease,
patent grafts, moderate aortic stenosis, patent previously
placed stents, elevated left sided filling pressure.
-Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of
exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed
perfusion defects and minor inferior defect.
-PACING/ICD:  N/A
3. OTHER PAST MEDICAL HISTORY:
Aortic stenosis s/p AVR
Anemia: baseline HCT 30-33
Hypothyroidism
OSA on CPAP
Depression
CKD
OA
Gout
IBS-diarrhea predominant
Obesity
PVD
UGI and LGI bleeding secondary to AVMs

MEDICATION ON ADMISSION: Allopurinol 150mg daily
Calcitriol 0.25mcg qT,Th,[**Last Name (LF) **],[**First Name3 (LF) **]
Calcitriol 0.5mcg qM,W,F
Ezetimibe 10mg daily
Insulin Aspart sliding scale
Insulin Lantus 50u qAM, 40u qPM
Levothyroid 224mcg daily
Metoprolol Succinate 100mg daily
NTG SL
Omeprazole 40mg daily
Sertraline 100mg daily
Simvastatin 80mg daily
Torsemide 60mg daily
Torsemide 40mg PRN increased edema
Vit C 500mg [**Hospital1 **]
ASA 81mg daily
MVI daily
Zinc 220mg daily

ALLERGIES: Atropine

PHYSICAL EXAM: VS: T=96.2 BP=120/70 HR=90 RR=20 O2 sat= 98% on 2L
GENERAL: WDWN male. Oriented x3. Mood, affect appropriate.  No
apparent distress
HEENT: large laceration noted over right aspect of skull with
bruising over his right orbit. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Cervical collar in place- unable to assess JVP.
CARDIAC: Regular rhythm with tachycardia.  Normal S1, S2. soft
apical holosystolic murmur.
LUNGS: Resp were unlabored, no accessory muscle use. Scattered
bibasilar crackles with no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

FAMILY HISTORY: There is no family history of sudden death.  Mother died of MI
in 60's, brother had MI at 53. His wife died of a brain aneurysm

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Retired [**Doctor Last Name **].
Widowed in [**2163-1-3**].  Several children live in the area.  He
receives VNA at home as well as assistance w/ other privately
hired help.
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Atrial flutter,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Unspecified viral infection,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Obstructive sleep apnea (adult)(pediatric),Irritable bowel syndrome,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Obesity, unspecified,Spinal stenosis in cervical region,Hypoxemia,Anemia, unspecified,Leukocytosis, unspecified,Tobacco use disorder,Long-term (current) use of insulin,Heart valve replaced by other means,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease
Subendo infarct, initial,Ac on chr syst hrt fail,Gastrointest hemorr NOS,Atrial flutter,Hyposmolality,Acute kidney failure NOS,Viral infection NOS,Syncope and collapse,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Osteoarthros NOS-unspec,Obstructive sleep apnea,Irritable bowel syndrome,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Depressive disorder NEC,Obesity NOS,Cervical spinal stenosis,Hypoxemia,Anemia NOS,Leukocytosis NOS,Tobacco use disorder,Long-term use of insulin,Heart valve replac NEC,Status-post ptca,Fam hx-ischem heart dis
Admission Date:  [**2166-12-28**]              [**Month/Day/Year **] Date:   [**2167-1-7**]

Date of Birth:  [**2094-10-7**]             Sex:   M

Service: MEDICINE

Allergies:
Atropine

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Malaise, shortness of breath

Major Surgical or Invasive Procedure:
cardioversion
endoscopy and flexible sigmoidoscopy


History of Present Illness:
Patient is a 72 y.o. Male w/ h.o. CAD s/p CABG [**2148**] w/ redo in
[**2163**] (has LIMA->LAD, SVG->LAD, SVG->OM in [**2148**], redo included
SVG-> PDA, SVG to prior LIMA), multiple stents (LMCA, D1 in
[**2160**]; PCI to SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]),
DM II, HL who presents as a transfer from OSH w/ NSTEMI.

He reports a few days of myalgias and general weakness/fatigue.
Along with this, he reports the sudden onset of chest pain,
which he described a different from his angina.  He took 1 SL
NTG with some relief but, given the persistence of his symptoms,
he presented to [**Hospital3 **].  Upon review of the [**Hospital1 **]
records, ED EKG showed  2:1 a-flutter at a rate of 120 with
RBBB.  He had no chest pain in the ED there and no SOB, but he
did report to the ED physician [**Name Initial (PRE) **] sense of general malaise.  He
was also noted to have a fever of 101 in the ED.  He was given
Acetaminophen for the fever, a chest xray was obtained which was
reportedly non-diagnostic as was a U/A.  His labwork was notable
for a Troponin T of 2.9, BNP 1070. He was thus transferred to
[**Hospital1 18**] for further evaluation.

In the ED, initial vitals were T97, HR 97, BP 105/68, RR 14, Sat
98% on 2L. His labwork was notable for a Troponin of 1.05,
BUN/Cr 41/1.7, plts 140, Hgb 10.8, INR 1.4, PTT 37.4.  He
continued to have right shoulder pain and was given Morphine 4mg
IV x 1. His blood pressure dropped to 87/56 after he received
the morphine so he received a 500cc bolus with good BP response.
 Portable CXR showed mild pulmonary vascular congestion with no
effusions.

On arrival to the floor, patient was stable but reported
lightheadedness.  Orthostatics at that time were normal and
lightheadedness resolved.  He went to the bathroom and was then
found down, blue and pulseless with agonal breathing.  CPR was
initiated but patient regained consciousness quickly.  No
medications or shocks were administered.  Rhythm was sinus with
hemodynamics were stable.  SBP was 140, oxygen sats were in the
mid-90s, HR was 80-90s.  Given syncopal event with
unresponsiveness, he is being transferred to the CCU for further
monitoring.

On arrival to the CCU, patient's oxygen saturations were in the
mid-high 80s on a NRB.  He denied any shortness of breath or
chest pain.  ABG showed that he was oxygenating well
(7.39/38/314/24).  Sats improved to 98% on 2L at the time of
this note.

On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.

Cardiac review of systems is notable for chest pain, dyspnea on
exertion, ankle edema and syncope.  He denies paroxysmal
nocturnal dyspnea, orthopnea, palpitations.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+),
Hypertension (-)
2. CARDIAC HISTORY:
AVF ([**10/2163**])
-CABG:  [**2163**], [**2148**] (LIMA-LAD, SVG LAD, SVG OM)
-PERCUTANEOUS CORONARY INTERVENTIONS:  LMCA, D1 in [**2160**]; PCI to
SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]
   -Cath [**10/2162**]: Three vessel native coronary artery disease,
patent grafts, moderate aortic stenosis, patent previously
placed stents, elevated left sided filling pressure.
-Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of
exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed
perfusion defects and minor inferior defect.
-PACING/ICD:  N/A
3. OTHER PAST MEDICAL HISTORY:
Aortic stenosis s/p AVR
Anemia: baseline HCT 30-33
Hypothyroidism
OSA on CPAP
Depression
CKD
OA
Gout
IBS-diarrhea predominant
Obesity
PVD
UGI and LGI bleeding secondary to AVMs

Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Retired [**Doctor Last Name **].
Widowed in [**2163-1-3**].  Several children live in the area.  He
receives VNA at home as well as assistance w/ other privately
hired help.

Family History:
There is no family history of sudden death.  Mother died of MI
in 60's, brother had MI at 53. His wife died of a brain aneurysm

several years ago and he currently lives alone.

Physical Exam:
VS: T=96.2 BP=120/70 HR=90 RR=20 O2 sat= 98% on 2L
GENERAL: WDWN male. Oriented x3. Mood, affect appropriate.  No
apparent distress
HEENT: large laceration noted over right aspect of skull with
bruising over his right orbit. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Cervical collar in place- unable to assess JVP.
CARDIAC: Regular rhythm with tachycardia.  Normal S1, S2. soft
apical holosystolic murmur.
LUNGS: Resp were unlabored, no accessory muscle use. Scattered
bibasilar crackles with no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

EXTREMITIES: [**1-4**]+ edema with no clubbing or cyanosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+

Pertinent Results:
Admission labs:
[**2166-12-28**] 12:40AM BLOOD WBC-8.0 RBC-3.29* Hgb-10.8* Hct-30.9*
MCV-94 MCH-32.9* MCHC-35.1* RDW-16.1* Plt Ct-140*
[**2166-12-28**] 12:40AM BLOOD PT-15.4* PTT-37.4* INR(PT)-1.4*
[**2166-12-28**] 12:40AM BLOOD Glucose-72 UreaN-41* Creat-1.7* Na-138
K-3.3 Cl-103 HCO3-23 AnGap-15
[**2166-12-28**] 07:31AM BLOOD Calcium-8.4 Phos-4.4# Mg-2.1
[**2166-12-28**] 07:31AM BLOOD TSH-0.28

Cardiac Biomarkers:
[**2166-12-28**] 12:40AM BLOOD cTropnT-1.05*
[**2166-12-28**] 07:31AM BLOOD CK-MB-6 cTropnT-1.10*
[**2166-12-28**] 02:15PM BLOOD CK-MB-5 cTropnT-0.93*
[**2166-12-29**] 03:48PM BLOOD CK-MB-3 cTropnT-1.15*
[**2166-12-29**] 03:48PM BLOOD CK(CPK)-56
[**2166-12-28**] 12:40AM BLOOD proBNP-7336*

Blood Gas:
[**2166-12-28**] 06:59AM BLOOD Type-ART pO2-35* pCO2-49* pH-7.31*
calTCO2-26 Base XS--2
[**2166-12-28**] 07:47AM BLOOD Type-ART pO2-314* pCO2-38 pH-7.39
calTCO2-24 Base XS--1

[**Month/Day/Year **] Labs:
[**2167-1-7**] 06:10AM BLOOD WBC-6.2 RBC-3.30* Hgb-11.1* Hct-30.6*
MCV-93 MCH-33.5* MCHC-36.2* RDW-21.1* Plt Ct-249
[**2167-1-7**] 06:10AM BLOOD PT-15.7* PTT-27.0 INR(PT)-1.4*
[**2167-1-7**] 06:10AM BLOOD Glucose-99 UreaN-70* Creat-1.8* Na-132*
K-4.4 Cl-95* HCO3-29 AnGap-12
[**2167-1-7**] 06:10AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.4

Micro:  Blood, urine, sputum cultures all negative.  H pylori
negative.

Studies:
CXR [**12-28**] FINDINGS: The cardiomediastinal and hilar contours are
stable, with mild cardiomegaly. There is mild degree of
pulmonary edema. The lung volumes are low. No focal
consolidation, pleural effusion or pneumothorax is identified.
Evidence of prior CABG, including intact sternotomy wires and
mediastinal surgical clips are present.
IMPRESSION: Mild pulmonary edema. No definite consolidation
detected.

CT spine [**12-28**]: IMPRESSION: No cervical spine fracture.
Spondylotic abnormalities, and other findings, noted above. MRI
scanning is more sensitive than CT imaging in detecting cord
injury from spondylosis/trauma, if clinically suspected.

CT head [**12-28**]: CONCLUSION: No intracranial hemorrhage.

Cervical spine MRI [**12-29**]:
IMPRESSIONS:
1. No evidence of ligamentous injury or disruption. Trace fluid
along the
anterior aspect of vertebral body of C5 through C7. No
fractures.
2. Moderate-to-severe canal stenosis between C3 and C6 (severe
at C5-C6) due to a combination of disc herniation and posterior
longitudinal ligament
thickening. Cord demonstrates associated myelomalacia, without
superimposed
acute abnormalities.
3. Multilevel neural foraminal narrowing, particularly on the
left.

Echo [**12-30**]:
Mild spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. Mild spontaneous echo contrast is present in
the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). Mild spontaneous echo contrast
is seen in the body of the right atrium. No mass or thrombus is
seen in the right atrium or right atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Global left
ventricular systolic function appears groslly preserved There
are complex (>4mm) atheroma in the descending thoracic aorta and
aortic arch. A bioprosthetic aortic valve prosthesis is present
and appears well-seated. The prosthetic aortic valve leaflets
appear normal The aortic valve prosthesis leaflets appear to
move normally. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.

IMPRESSION: No intracardiac thrombus. Mild spontaneous echo
contrast and left and right atrium. Normally functioning
bioprosthetic aortic valve. Mild mitral regurgitation. Complex,
non-mobile plaque in the thoracic aorta.

Echo [**2167-1-5**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
inferior and infero-lateral akinesis. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. with mild global free wall hypokinesis. The diameters of
aorta at the sinus, ascending and arch levels are normal. A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2166-8-12**],
the LVEF has decreased. The RV is probably similar. If
indicated, a cardiac MRI may more accurately assess LVEF.

EKG on admission [**12-28**]:
Underlying atrial mechanism not certain with differential
diagnosis including atrial fibrillation or atrial flutter
variant versus atrial tachycardia with variable block. Right
bundle-branch block with left axis deviation consistent with
left anterior fascicular block. Underlying inferior Q wave
myocardial infarction. Single ventricular premature beat is also
present. Non-specific ST-T wave change with slight QTc interval
prolongation. Compared to the previous tracing of [**2165-8-16**] atrial
tachy-arrhythmia is new. Clinical correlation is suggested.

EKG [**2167-1-5**]:
Sinus rhythm. Right bundle-branch block with left anterior
fascicular block. Prior inferior myocardial infarction. Compared
to the previous tracing no major change.

[**1-6**] Upper endoscopy/enteroscopy:  Antral erosions, no focal
bleed
[**1-6**] Flex Sig:  No source of bleed

Brief Hospital Course:
72yo male with history of CAD s/p CABG x 2 who presents from OSH
with NSTEMI. Transferred to the CCU s/p syncopal event.
.
# Syncope: His transfer to the CCU was initiated because of a
syncopal episode. Possible etiologies included vasovagal episode
(he was baring down in the bathroom at the time), arrhythmia
given his a-flutter/a-fib and sigificant cardiac history. He was
not on tele at the time of the event, and he was found down,
pulseless in the bathroom. Compressions were initiated and he
quickly regained consciousness, and was lucid. He was not
confused, and had no evidence of seizure activity.  In the CCU,
tele showed a-fib with RVR and was uptitrated to 75 TID of
metoprolol tartrate and then initiated on a diltiazem drip.  His
rate slowed, but he remained in a-fib. He was put on a heparin
drip and started on coumadin for a CHADS2 score of 3. He was DC
cardioverted and remained in NSR through [**Month/Day (4) **]. Of note, his
anticoagulation was stopped in-house in the setting of
developing LGIB (see below), and was discharged on beta blocker
but no coumadin.  He will require follow up for reassessment of
his need for coumadin given his recent bleed.
.
# NSTEMI: Pt was first seen at [**Hospital3 4107**] with 2 days of
chest pain and was noted to have a positive troponin-I of 2.92.
His troponin-T in the [**Hospital1 18**] ED was 1.05, prior troponins in [**2164**]
ranged from 0.05->0.23 in the setting of his renal dysfunction.
His troponins remained elevated in the 1's but his CK decreased
and his CK-MB were normal. He also had renal dysfunction, likely
contributing to his poor clearance of troponins.  In the setting
of his renal function, cath was deferred, but may be considered
in the future.  He was d/c'd on beta blocker (metoprolol
succinate increased to 150mg daily from home dose of 100mg),
asa, satin.
.
#LGIB:  Pt noted to have Guaiac positive stools and occasional
BRBPR.  His Hct was noted to drop from 33.5-->26.5 over the
course of 1 day and received a total of 1 U PRBC with good
response.  Pt had both upper endoscopy and colonoscopy which was
only significant for antral erosisons but no obvious source of
bleed.  His anticoagulation was held and he was continued on PPI
which was increased to [**Hospital1 **] on [**Hospital1 **].  After endoscopy, he
had no further signs of bleeding and hct stable at 30-32. H
pylori was negative.  He was set up with GI follow up.
.
#Acute on chronic systolic Congestive Heart Failure:  Pt with
echo in-house showing worsening LVEF to 40% compared to prior
echo.  He was noted to be volume overloaded in house requiring
diuresis with metolazone and toresemide, along with home dose of
spironalactone.  Over the course of his CCU and floor stay he
diuresed well and became more euvolemic after transfer back to
the floor.  He was discharged on a regimen of torsemide 60 mg
daily, with instructions to take an additional 40mg as needed,
as well as home spironalactone of 25 mg daily.  He was told to
follow up with Dr. [**First Name (STitle) 437**] in heart failure clinic.
.
# Fever/leukocytosis: He spiked a fever overnight on the night
of his transfer to the CCU to 101F. He had pan cultures taken
(blood, urine, sputum) and a chest x-ray was done, but no focal
source was identified. Antibiotics were initially held in the
setting of a lack of source/bug, and given his hemodynamic
stability.  Given the presentation of malaise and myalgias it
was thought that he had a viral syndrome.
.
# Hypoxia: He was hypoxic to the the high 80's on NRB initially
on transfer to the CCU, and was able to be weaned without
intervention to 2L NC and maintained sats in the low to mid 90s.
PE was considered as well as CHF exacerbation, ACS,
hypoventilation, methemoglobinemia, and COPD. Because of his
normal ABG and his normal methemoglobin, as well as his
downtrending CK-MBs he was thought to be overloaded. He had been
in a-fib with RVR, with likely poor forward flow. He had
increased crackles on exam and required diuresis with good
improvement in his respiratory status.
.
# CKD: Patient has stage III CKD thought to be secondary to CHF.
 He is followed by Dr. [**Last Name (STitle) **] as an outpatient.  Creatinine at
baseline on arrival (1.7) and increased likely secondary to poor
forward flow to as high as 2.3. He was continued on home
spironalactone, torsemide, and metolazone, and his Cr improved
to 1.8 on [**Last Name (STitle) **]
.
# DM II: He was continued on his home regimen of Lantus [**Hospital1 **]
(40qAM, 50qPM) and ISS.
.
# Hypothyroidism: Continued on Levothyroxine 280mcg qAM. TSH was
WNL.
.
# Depression: Continued on home sertraline


Medications on Admission:
Allopurinol 150mg daily
Calcitriol 0.25mcg qT,Th,[**Last Name (LF) **],[**First Name3 (LF) **]
Calcitriol 0.5mcg qM,W,F
Ezetimibe 10mg daily
Insulin Aspart sliding scale
Insulin Lantus 50u qAM, 40u qPM
Levothyroid 224mcg daily
Metoprolol Succinate 100mg daily
NTG SL
Omeprazole 40mg daily
Sertraline 100mg daily
Simvastatin 80mg daily
Torsemide 60mg daily
Torsemide 40mg PRN increased edema
Vit C 500mg [**Hospital1 **]
ASA 81mg daily
MVI daily
Zinc 220mg daily

[**Hospital1 **] Medications:
1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).

2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
3. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 3X/WEEK
(MO,WE,FR).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day: Also take 40 units in the evening.
6. insulin aspart 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
7. levothyroxine 112 mcg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
8. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day:
[**Month (only) 116**] take additional 40 mg as needed.
16. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

19. Outpatient Lab Work
Please check Chem-7 and CBC on [**2167-1-9**] and call results to Dr.
[**First Name (STitle) **] at [**Telephone/Fax (1) 62**] thanks


[**Telephone/Fax (1) **] Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

[**Hospital3 **] Diagnosis:
Acute on chronic Systolic congestive Heart Failure
Atrial Fibrillation
Non ST Elevation Myocardial Infarction
Upper and Lower GI Bleed
Diabetes Mellitus Type 2


[**Hospital3 **] Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


[**Hospital3 **] Instructions:
You had chest pain and was admitted to [**Hospital3 **] with a
heart attack. You were transferred to [**Hospital1 18**] and had a fainting
episode in the bathroom. You were in an irregular heart rhythm,
atrial fibillation, that was converted to a normal rhythm with
an electrical cardioversion. You will need to have your heart
rhythm checked regularly now. We started an anticoagulation pill
called coumadin to prevent strokes from the atrial fibrillation
and you developed a bleed somewhere in your GI tract. We were
unable to localize the bleeding using a scope in your stomach
and lower [**Hospital1 499**]. It is very important that you follow a diabetic
and low salt diet. This will prevent your blood sugars from
being high and prevent the fluid from reaccumulating. Weigh
yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Your weight at [**Last Name (NamePattern1) **] is 184 pounds. Please make an appt with
your diabetes doctor soon to review your diet and insulin
requirements. We were unable to perform a cardiac
catheterization during this hospital stay because of your kidney
function worsened.
.
We made the following changes to your medicines:
1. Increase Metoprolol to 150 mg daily
2. Increase Omeprazole to 40 mg twice daily
3. Increase aspirin to 325 mg daily


Followup Instructions:
You have following appointments scheduled for you:
.
Department: CARDIAC SERVICES
When: Tuesday [**2167-1-13**] at 1:00 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: [**Hospital3 249**]
When: THURSDAY [**2167-1-22**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], [**Last Name (NamePattern1) 280**] [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2167-3-17**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2167-4-7**] at 3:00 PM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2167-1-21**] at 1 PM
With: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Atrial flutter,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Unspecified viral infection,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Obstructive sleep apnea (adult)(pediatric),Irritable bowel syndrome,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Obesity, unspecified,Spinal stenosis in cervical region,Hypoxemia,Anemia, unspecified,Leukocytosis, unspecified,Tobacco use disorder,Long-term (current) use of insulin,Heart valve replaced by other means,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease'}


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: Malaise, shortness of breath

PRESENT ILLNESS: Patient is a 72 y.o. Male w/ h.o. CAD s/p CABG [**2148**] w/ redo in
[**2163**] (has LIMA->LAD, SVG->LAD, SVG->OM in [**2148**], redo included
SVG-> PDA, SVG to prior LIMA), multiple stents (LMCA, D1 in
[**2160**]; PCI to SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]),
DM II, HL who presents as a transfer from OSH w/ NSTEMI.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+),
Hypertension (-)
2. CARDIAC HISTORY:
AVF ([**10/2163**])
-CABG:  [**2163**], [**2148**] (LIMA-LAD, SVG LAD, SVG OM)
-PERCUTANEOUS CORONARY INTERVENTIONS:  LMCA, D1 in [**2160**]; PCI to
SVG to LAD, ISR of D1 stent in [**2161**]; LMCA in [**2162**]
   -Cath [**10/2162**]: Three vessel native coronary artery disease,
patent grafts, moderate aortic stenosis, patent previously
placed stents, elevated left sided filling pressure.
-Stress test [**2162-5-24**]: Poor functional status. 3.5 minutes of
exercise on [**Doctor Last Name 4001**] protocol. EF 30% and multiple fixed
perfusion defects and minor inferior defect.
-PACING/ICD:  N/A
3. OTHER PAST MEDICAL HISTORY:
Aortic stenosis s/p AVR
Anemia: baseline HCT 30-33
Hypothyroidism
OSA on CPAP
Depression
CKD
OA
Gout
IBS-diarrhea predominant
Obesity
PVD
UGI and LGI bleeding secondary to AVMs

MEDICATION ON ADMISSION: Allopurinol 150mg daily
Calcitriol 0.25mcg qT,Th,[**Last Name (LF) **],[**First Name3 (LF) **]
Calcitriol 0.5mcg qM,W,F
Ezetimibe 10mg daily
Insulin Aspart sliding scale
Insulin Lantus 50u qAM, 40u qPM
Levothyroid 224mcg daily
Metoprolol Succinate 100mg daily
NTG SL
Omeprazole 40mg daily
Sertraline 100mg daily
Simvastatin 80mg daily
Torsemide 60mg daily
Torsemide 40mg PRN increased edema
Vit C 500mg [**Hospital1 **]
ASA 81mg daily
MVI daily
Zinc 220mg daily

ALLERGIES: Atropine

PHYSICAL EXAM: VS: T=96.2 BP=120/70 HR=90 RR=20 O2 sat= 98% on 2L
GENERAL: WDWN male. Oriented x3. Mood, affect appropriate.  No
apparent distress
HEENT: large laceration noted over right aspect of skull with
bruising over his right orbit. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Cervical collar in place- unable to assess JVP.
CARDIAC: Regular rhythm with tachycardia.  Normal S1, S2. soft
apical holosystolic murmur.
LUNGS: Resp were unlabored, no accessory muscle use. Scattered
bibasilar crackles with no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

FAMILY HISTORY: There is no family history of sudden death.  Mother died of MI
in 60's, brother had MI at 53. His wife died of a brain aneurysm

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Retired [**Doctor Last Name **].
Widowed in [**2163-1-3**].  Several children live in the area.  He
receives VNA at home as well as assistance w/ other privately
hired help. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hemorrhage of gastrointestinal tract, unspecified,Atrial flutter,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Unspecified viral infection,Syncope and collapse,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Obstructive sleep apnea (adult)(pediatric),Irritable bowel syndrome,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Obesity, unspecified,Spinal stenosis in cervical region,Hypoxemia,Anemia, unspecified,Leukocytosis, unspecified,Tobacco use disorder,Long-term (current) use of insulin,Heart valve replaced by other means,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease'}
