CHIEF COMPLAINT: Pericardial tamponade

PRESENT ILLNESS: EVENTS / HISTORY OF PRESENTING ILLNESS:
75 year old male with a history of IDDM, HTN and CKD with recent
admission for LLE cellulitis treated with Augmentin (he has 4
days left on this course) who was seen in clinic for malaise and
admitted based on his laboratory results (Na of 129, anemia with
HCT of 29.4 and acute renal failure with Cr of 3.2 from baseline
of 2.0).
.
In the ED, vitals were: T:97.8, HR:102, BP:129/109, RR:20,
O2Sat:95% on RA. He was found to have a UTI and was given
Unasyn. He was given 2L normal saline for his sodium of 126 and
admitted to night float.
.
The patient reports he was in his usual state of health which
includes walking daily until Friday when he awoke from his nap
and experienced shaking chills and whole chest, back and
shoulder pain "in the muscles". He states that this improved
after he was wrapped in several blankets. Then Saturday at 2 am,
he awoke to check his blood glucose and noted whole chest, arm
and back pain. He was unable to clarify this pain further other
than to say it was unbearable. He states it was worse with
movement, lying flat, and deep inspiration. He took tylenol and
it resolved. He reports generalized fatigue, and decreased
appetite. He developed nausea on monday prior to admission, and
the day before admission felt unwell and saw his PCP. [**Name10 (NameIs) **] clinic
he was felt to have a viral syndrome and was sent home with
precautions. He recalled and admitted for lab abnormalities as
above.
.
On morning assessment the patient was found to be in atrial
fibrillation with rapid ventricular rate up to 150, hypotensive
down to systolic 70s, temp 99.9, and respiratory distress 93% on
4LNC. The patient also endorsed pleuritic chest pain, similar to
the pain he had no the saturday prior to admission. Due to his
clinical deterioration, the patient was transferred to the MICU
for further care.
While in the MICU the patient had a TTE that showed a large
pericardial effusion with evidence of tamponade (LVEF 55%).  He
was taken for an urgent pericardiocentesis. He continued on a
course of antibiotics for a UTI.
.
In the cardiac cath lab he had 600 cc of clear pericardial fluid
drained.
On arrival to the CCU his chest pain was resolving and his
breathing was improved.
.
ROS: The patient denies any dyspnea, fevers, diarrhea,
constipation ( BM [**8-2**] ), vomiting, dysuria. He does report
decreased amount of urine recently. He also endorses fatigue,
malaise, poor appetite. No increased leg swelling, at baseline
his left leg is swollen since a prior broken leg. He endorses
dyspnea on exertion and exertional angina with walking up stairs
quickly or walking carrying heavy bundles.  The shortness of
breath has been most notable over the past 3 days.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
IDDM * 45 years
Hypercholesterolemia
Hypertension
CKD, from acute phosphate nephropathy, baseline (2-2.4)
Anemia, attributed to CKD, on procrit, baseline HCT 33-36
Coronary artery disease s/p MI in ; negative ETT- echo for
ischemia in [**8-23**]
Celiac sprue
BPH, [**2158**] bx negative, PSA [**1-18**] 4.5, [**3-22**] 3.6, [**4-24**] 4.5
Thyroid nodule
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: none
.
Percutaneous coronary intervention: [**2150**] with PTCA of the mid
RCA and OM2
.
Pacemaker/ICD placed: none

MEDICATION ON ADMISSION: Aspirin 325 mg daily
Isosorbide dinitrate 20 mg po tid (pt reports as 40mg am, and
20mg pm)
Metoprolol 12.5 mg po bid
Simvastatin 40 mg daily
fluticasone nasal spray
Fluticasone-Salmeterol 250/50 inh [**Hospital1 **]
Albuterol
Glargine 6 u subq daily
Lispro sliding scale
Montelukast 10 mg daily
Calcitriol 0.25 mg po daily
Sevelamer 400 mg po tid -- patient has not been taking this
Tamsulosin 0.4 mg daily
MVI
Polysaccharide Iron Complex 150 mg Capsule [**Hospital1 **]
Loratadine 10 mg daily
Augmentin 500/125 [**Hospital1 **]

ALLERGIES: Gluten

PHYSICAL EXAM: VS: 98.5  128 95/66  29  91%10L
PA 47/24
Gen: WDWN elderly Russian male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP elevated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: pericardial drain in place. No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored. crackles at lateral
bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. arterial and venous access in
right groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: None

SOCIAL HISTORY: Born in [**Country 532**], moved to US in [**2150**]. Lives with his wife. Former
organic chemistry professor. He has never smoked. He does not
consume alcohol on a regular basis (1 drink every 2-3 months).
Acute idiopathic pericarditis,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Cardiogenic shock,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Cardiac tamponade,Atrial fibrillation,Long-term (current) use of insulin,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hyperpotassemia,Celiac disease,Anemia in chronic kidney disease,Pure hypercholesterolemia
Ac idiopath pericarditis,Acute kidney failure NOS,Cellulitis of leg,Cardiogenic shock,Acute respiratry failure,Ac on chr diast hrt fail,Ac DVT/emb distl low ext,Cardiac tamponade,Atrial fibrillation,Long-term use of insulin,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,DMII wo cmp uncntrld,Hyperpotassemia,Celiac disease,Anemia in chr kidney dis,Pure hypercholesterolem
Admission Date:  [**2164-8-2**]              Discharge Date:   [**2164-8-11**]

Date of Birth:  [**2089-7-2**]             Sex:   M

Service: MEDICINE

Allergies:
Gluten

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Pericardial tamponade

Major Surgical or Invasive Procedure:
Pericardiocentesis

History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS:
75 year old male with a history of IDDM, HTN and CKD with recent
admission for LLE cellulitis treated with Augmentin (he has 4
days left on this course) who was seen in clinic for malaise and
admitted based on his laboratory results (Na of 129, anemia with
HCT of 29.4 and acute renal failure with Cr of 3.2 from baseline
of 2.0).
.
In the ED, vitals were: T:97.8, HR:102, BP:129/109, RR:20,
O2Sat:95% on RA. He was found to have a UTI and was given
Unasyn. He was given 2L normal saline for his sodium of 126 and
admitted to night float.
.
The patient reports he was in his usual state of health which
includes walking daily until Friday when he awoke from his nap
and experienced shaking chills and whole chest, back and
shoulder pain "in the muscles". He states that this improved
after he was wrapped in several blankets. Then Saturday at 2 am,
he awoke to check his blood glucose and noted whole chest, arm
and back pain. He was unable to clarify this pain further other
than to say it was unbearable. He states it was worse with
movement, lying flat, and deep inspiration. He took tylenol and
it resolved. He reports generalized fatigue, and decreased
appetite. He developed nausea on monday prior to admission, and
the day before admission felt unwell and saw his PCP. [**Name10 (NameIs) **] clinic
he was felt to have a viral syndrome and was sent home with
precautions. He recalled and admitted for lab abnormalities as
above.
.
On morning assessment the patient was found to be in atrial
fibrillation with rapid ventricular rate up to 150, hypotensive
down to systolic 70s, temp 99.9, and respiratory distress 93% on
4LNC. The patient also endorsed pleuritic chest pain, similar to
the pain he had no the saturday prior to admission. Due to his
clinical deterioration, the patient was transferred to the MICU
for further care.
While in the MICU the patient had a TTE that showed a large
pericardial effusion with evidence of tamponade (LVEF 55%).  He
was taken for an urgent pericardiocentesis. He continued on a
course of antibiotics for a UTI.
.
In the cardiac cath lab he had 600 cc of clear pericardial fluid
drained.
On arrival to the CCU his chest pain was resolving and his
breathing was improved.
.
ROS: The patient denies any dyspnea, fevers, diarrhea,
constipation ( BM [**8-2**] ), vomiting, dysuria. He does report
decreased amount of urine recently. He also endorses fatigue,
malaise, poor appetite. No increased leg swelling, at baseline
his left leg is swollen since a prior broken leg. He endorses
dyspnea on exertion and exertional angina with walking up stairs
quickly or walking carrying heavy bundles.  The shortness of
breath has been most notable over the past 3 days.

Past Medical History:
PAST MEDICAL HISTORY:
IDDM * 45 years
Hypercholesterolemia
Hypertension
CKD, from acute phosphate nephropathy, baseline (2-2.4)
Anemia, attributed to CKD, on procrit, baseline HCT 33-36
Coronary artery disease s/p MI in ; negative ETT- echo for
ischemia in [**8-23**]
Celiac sprue
BPH, [**2158**] bx negative, PSA [**1-18**] 4.5, [**3-22**] 3.6, [**4-24**] 4.5
Thyroid nodule
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: none
.
Percutaneous coronary intervention: [**2150**] with PTCA of the mid
RCA and OM2
.
Pacemaker/ICD placed: none

Social History:
Born in [**Country 532**], moved to US in [**2150**]. Lives with his wife. Former
organic chemistry professor. He has never smoked. He does not
consume alcohol on a regular basis (1 drink every 2-3 months).


Family History:
None

Physical Exam:
VS: 98.5  128 95/66  29  91%10L
PA 47/24
Gen: WDWN elderly Russian male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP elevated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: pericardial drain in place. No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored. crackles at lateral
bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. arterial and venous access in
right groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: alert and oriented x3 moving all 4 extremities
symmetrically

Pertinent Results:
[**2164-8-1**] 09:45PM   WBC-8.8 RBC-3.15* HGB-9.9* HCT-30.0* MCV-95
MCH-31.5 MCHC-33.1 RDW-13.4
[**2164-8-1**] 09:45PM   GLUCOSE-307* UREA N-54* CREAT-3.9*
SODIUM-126* POTASSIUM-4.8 CHLORIDE-90* TOTAL CO2-22 ANION GAP-19
[**2164-8-2**] 05:27AM   CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2164-8-1**] 09:45PM   PT-13.3 PTT-24.8 INR(PT)-1.1

[**2164-8-1**] 09:45PM   CK(CPK)-28*
[**2164-8-1**] 09:45PM   CK-MB-3 cTropnT-<0.01
[**2164-8-2**] 08:44AM BLOOD CK(CPK)-21*
[**2164-8-2**] 08:44AM BLOOD CK-MB-NotDone cTropnT-<0.01

[**2164-8-2**] 03:45PM PERICARDIAL FLUID  TOT PROT-5.0 GLUCOSE-349
LD(LDH)-369 AMYLASE-25 ALBUMIN-2.9
[**2164-8-2**] 03:45PM PERICARDIAL FLUID  WBC-2335* RBC-[**Numeric Identifier 8130**]*
POLYS-61* LYMPHS-14* MONOS-7* EOS-2* MESOTHELI-6* MACROPHAG-6*
OTHER-4*
[**2164-8-2**] 3:45 pm FLUID,OTHER      PERICARDIAL FLUID.
   GRAM STAIN (Final [**2164-8-2**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2164-8-5**]):    NO GROWTH.
   ANAEROBIC CULTURE (Final [**2164-8-8**]):    NO GROWTH.
   ACID FAST SMEAR (Final [**2164-8-3**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
   ACID FAST CULTURE (Preliminary):
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
[**2164-8-2**] PERICARDIAL FLUID CYTOLOGY: NEGATIVE FOR MALIGNANT
CELLS.
[**2164-8-7**] 05:40AM BLOOD TSH-2.4
[**2164-8-7**] 05:40AM BLOOD T4-8.3 Free T4-1.7
[**2164-8-3**] 04:37AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:80  [**Last Name (un) **]
[**2164-8-3**] 04:37AM BLOOD RheuFac-23*

L LENI [**2164-8-1**]: No evidence of left lower extremity DVT.

L TIB/FIB XR: No radiographic evidence of osteomyelitis.

CXR [**2164-8-1**]: Dense left basilar opacity, with at least some
component of
pleural fluid, possibly also representing some pneumonic
consolidation or
atelectasis.

EKG [**2164-8-2**]: Atrial fibrillation with rapid ventricular
response. Low voltage in limb leads. Non-specific inferolateral
ST-T wave changes. Compared to the previous tracing of [**2160-2-7**]
the rhythm is now atrial fibrillation. Limb lead voltage is
lower. Clinical correlation is suggested. The precordial lead
voltage is also lower.

URINE CULTURE [**2164-8-2**]: No growth.

Brief Hospital Course:
75 yo M w/ IDDM, CKD, HTN, presented with malaise, respiratory
failure and renal failure, found to have pericardial effusion,
s/p pericardiocentesis, developed Afib with RVR, pleural
effusion.
.
# Pericardial effusion:
TTE showed a large pericardial effusion with evidence of
tamponade. He was taken to the cardiac cath lab for an urgent
pericardiocentesis. Approximately 600 cc of clear pericardial
fluid was drained, resulting in improvement in his symptoms. The
tap was traumatic, but the pericardial fluid was clear and
non-bloody per report. Cytology revealed no malignant cells.
Echo following pericardiocentesis showed decreased pericardial
effusion and no signs of tamponade. The patient was monitored
clinically and with repeat echocardiograms which demonstrated
further decreases in the size of the pericardial effusion. The
effusion was likely of viral etiology given his history of
recent prodromal symptoms. Less likely etiologies include
malignancy (dysplastic nevi noted - r/o melanoma; has not been
seen by a dermatologist in >10 years), vs. thyroid (TFTs normal)
vs. autoimmune (RF and [**Doctor First Name **] neg) vs. Dresslers (CE negative on
admission with no known recent cardiac events) vs. uremic (Cr
bump likely not significant enough per Renal). Pt has scheduled
outpatient follow up with cardiologist as well as dermatology.
.
# Pleural effusion/Respiratory failure/Diastolic CHF:
On initial presentation, he was noted to be in respiratory
distress and had a significant oxygen requirement. Significant
bilateral pleural effusions were noted on CXR and the patient
was clinically noted to have bilateral crackles and LE edema. He
was diuresed, responding well to Lasix 20 mg IV and then 40 mg
PO. His oxygen requirement gradually decreased. A pleural tap
was considered but as pt subsequently with improvement on
clinical exam and CXR, diuresis continued with continued
improvement. On the final day of admission it was noted that the
pt's oxygen sats were stable, but after diuresis the prior day
the patient was mildly hypovolemic, with BP dropping to 80's
systolic on standing. This was thought to be in part due to
restarting his Flomax the night before and also in part due to
vigorous diuresis. The patient was not discharged on a standing
dose of lasix, and instead was instructed to follow up with
outpatient doctor in a week to determine whether standing lasix
would be necessary. On discharge, patient with no home oxygen
requirement; satting in high 90s at rest, desats to low 90s on
ambulation.
.
# Atrial fibrillation
Pt developed paroxysmal atrial fibrillation which converted to
sinus rhythm either spontaneously or after administration of
Metoprolol 5-10 mg IV.  However, as patient continued to have
frequent episodes of a fib, amiodarone initiated.  He was
started on amiodarone on [**8-7**], with plans to give 400mg [**Hospital1 **] for
7 days, then 400mg QD for 7 days, and then 200mg QD. Baseline
TFTs and LFTs wnl.  Pt will need to have PFTs checked as an
outpatient. As he has a CHADS score of 4, patient was started on
anticoagulation with Coumadin with a goal INR of 1.8-2.5 as
patient with recent pericardial tap and on amiodarone.  [**Hospital 197**]
clinic notified of goal INR.
.
# R Tibial DVT:
LENIs showed thrombus in R tibial vein. Lower leg DVT is not
likely to result in significant thromboembolism, and given his
acute on chronic renal failure, he probably would not tolerate a
PE CT well, so no workup for possible PE was pursued.  However,
pt adequately treated as already on systemic anticoagulation for
Afib and ASA for CAD.
.
# Acute on chronic renal failure:
FeNa 0.1%, suggestive of prerenal etiology.  Likely [**2-18**] poor
forward flow in setting of volume overload/pericardial
tamponade.  Urine output and Cr improved with diuresis.
.
# Cellulitis:
Keflex initially started for cellulitic area on left leg.
However, this was discontinued as outside records showed that pt
had already completed a 14 day course of Augmentin.  I&D was not
indicated by physical exam.
.
# CAD
No evidence of acute ischemic event on EKG or cardiac enzymes
(negative over 12 hours).  Patient continued on ASA, statin,
beta blocker.
.
# UTI:
Pt originally admitted with a question of possible UTI and
treated with cipro, but as Ucx was negative, this was
discontinued.
.
# Anemia:
Hct was stable. Anemia is attributed to renal failure.  Fe
stores appear replete. Pt continued on Procrit.
.
# DM - Type I per records
Pt was treated with glargine and lispro sliding scale. Due to
high blood sugars, his glargine dosage was increased.  Pt should
discuss with PCP whether [**Name9 (PRE) **] clinic could help him improve
his glycemic control.

Medications on Admission:
Aspirin 325 mg daily
Isosorbide dinitrate 20 mg po tid (pt reports as 40mg am, and
20mg pm)
Metoprolol 12.5 mg po bid
Simvastatin 40 mg daily
fluticasone nasal spray
Fluticasone-Salmeterol 250/50 inh [**Hospital1 **]
Albuterol
Glargine 6 u subq daily
Lispro sliding scale
Montelukast 10 mg daily
Calcitriol 0.25 mg po daily
Sevelamer 400 mg po tid -- patient has not been taking this
Tamsulosin 0.4 mg daily
MVI
Polysaccharide Iron Complex 150 mg Capsule [**Hospital1 **]
Loratadine 10 mg daily
Augmentin 500/125 [**Hospital1 **]

Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
every 2 weeks.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed.
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: Last dose on [**2164-8-13**].
Disp:*10 Tablet(s)* Refills:*0*
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: Start on [**8-14**] and continue for 7 days. .
Disp:*14 Tablet(s)* Refills:*0*
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2164-8-21**].
Disp:*30 Tablet(s)* Refills:*2*
16. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
17. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
18. Lispro insulin
Please continue home sliding scale.
19. Lantus 100 unit/mL Cartridge Sig: Twelve (12) units
Subcutaneous once a day.
20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services

Discharge Diagnosis:
Primary:
Pericardial effusion
Acute on chronic diastolic dysfunction
Acute on chronic renal failure
Paroxysmal atrial fibrillation
.
Secondary:
Anemia of chronic disease
Diabetes type I on insulin
Hypercholesterolemia
Hypertension
Coronary artery disease s/p MI in [**2150**]
Celiac sprue
BPH
Thyroid nodule


Discharge Condition:
Stable


Discharge Instructions:
You had fluid around your heart called a pericardial effusion
that was tapped and has not reaccumulated.
You have fluid near the base of your lungs called pleural
effusions. You were started on a diuretic which improved the
effusions, it also helped to decrease the fluid in the rest of
your body.

You have atrial fibrillation, a new irregular heart beat, and
you were started on amiodarone to control the rhythm and
coumadin to prevent blood clots. The dose of amiodarone for the
first 2 days that you are at home is 400mg twice daily, the dose
of amiodarone after that will be 200mg twice daily for 1 week,
the dose of amiodarone after that will be 200mg once daily
continuously.
You were noted to have a blood clot in your left calf and the
coumadin should help to dissolve this.
You were noted to have many moles on your skin and should follow
up with Dermatology.
.
You were started on the following new medications:
- Amiodarone
- Coumadin (dose adjusted by coumadin clinic)
- Lovenox (take until coumadin level therapeutic)
The following medications were changed:
- Metoprolol 12.5 daily twice daily -> Toprol XL 75 mg daily
- Glargine increased to 12 U daily
The following medications were discontinued:
- Isosorbide dinitrate
- Augmentin
Please take all medications as prescribed.
.
Please check your blood sugars before meals.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet so that you don't retain fluid.
Please use your TEDS stockings every day and keep your legs
elevated when you are sitting down.
.
If you experience chest pain, worsening shortness of breath,
weakness on one side of your body, difficulty speaking or
swallowing, fever/chills, please call 911 or go to the ER.

Followup Instructions:
You have the following appointments:
Primary Care:
Provider: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2164-8-21**] 8:10
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2164-8-31**] 10:30
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2164-9-10**] 2:10
Please speak with your PCP about whether you may benefit from an
appointment at the [**Hospital **] clinic ([**Telephone/Fax (1) 8131**]) for better
control of your blood sugars.
.
Cardiology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Office will
call you at home with appt.  Please follow up lasix dose which
was used inpatient for diuresis.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2164-11-29**] 9:20
.
[**Hospital 197**] Clinic at [**Hospital6 733**]: [**Telephone/Fax (1) 2173**]. They
will call you to arrange follow-up of your coumadin levels.
.
Dermatology:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] Phone: ([**Telephone/Fax (1) 8132**] Date/Time: [**10-30**]
at 1:45pm.
{'Acute idiopathic pericarditis,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Cardiogenic shock,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Cardiac tamponade,Atrial fibrillation,Long-term (current) use of insulin,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hyperpotassemia,Celiac disease,Anemia in chronic kidney disease,Pure hypercholesterolemia'}


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: Pericardial tamponade

PRESENT ILLNESS: EVENTS / HISTORY OF PRESENTING ILLNESS:
75 year old male with a history of IDDM, HTN and CKD with recent
admission for LLE cellulitis treated with Augmentin (he has 4
days left on this course) who was seen in clinic for malaise and
admitted based on his laboratory results (Na of 129, anemia with
HCT of 29.4 and acute renal failure with Cr of 3.2 from baseline
of 2.0).
.
In the ED, vitals were: T:97.8, HR:102, BP:129/109, RR:20,
O2Sat:95% on RA. He was found to have a UTI and was given
Unasyn. He was given 2L normal saline for his sodium of 126 and
admitted to night float.
.
The patient reports he was in his usual state of health which
includes walking daily until Friday when he awoke from his nap
and experienced shaking chills and whole chest, back and
shoulder pain "in the muscles". He states that this improved
after he was wrapped in several blankets. Then Saturday at 2 am,
he awoke to check his blood glucose and noted whole chest, arm
and back pain. He was unable to clarify this pain further other
than to say it was unbearable. He states it was worse with
movement, lying flat, and deep inspiration. He took tylenol and
it resolved. He reports generalized fatigue, and decreased
appetite. He developed nausea on monday prior to admission, and
the day before admission felt unwell and saw his PCP. [**Name10 (NameIs) **] clinic
he was felt to have a viral syndrome and was sent home with
precautions. He recalled and admitted for lab abnormalities as
above.
.
On morning assessment the patient was found to be in atrial
fibrillation with rapid ventricular rate up to 150, hypotensive
down to systolic 70s, temp 99.9, and respiratory distress 93% on
4LNC. The patient also endorsed pleuritic chest pain, similar to
the pain he had no the saturday prior to admission. Due to his
clinical deterioration, the patient was transferred to the MICU
for further care.
While in the MICU the patient had a TTE that showed a large
pericardial effusion with evidence of tamponade (LVEF 55%).  He
was taken for an urgent pericardiocentesis. He continued on a
course of antibiotics for a UTI.
.
In the cardiac cath lab he had 600 cc of clear pericardial fluid
drained.
On arrival to the CCU his chest pain was resolving and his
breathing was improved.
.
ROS: The patient denies any dyspnea, fevers, diarrhea,
constipation ( BM [**8-2**] ), vomiting, dysuria. He does report
decreased amount of urine recently. He also endorses fatigue,
malaise, poor appetite. No increased leg swelling, at baseline
his left leg is swollen since a prior broken leg. He endorses
dyspnea on exertion and exertional angina with walking up stairs
quickly or walking carrying heavy bundles.  The shortness of
breath has been most notable over the past 3 days.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
IDDM * 45 years
Hypercholesterolemia
Hypertension
CKD, from acute phosphate nephropathy, baseline (2-2.4)
Anemia, attributed to CKD, on procrit, baseline HCT 33-36
Coronary artery disease s/p MI in ; negative ETT- echo for
ischemia in [**8-23**]
Celiac sprue
BPH, [**2158**] bx negative, PSA [**1-18**] 4.5, [**3-22**] 3.6, [**4-24**] 4.5
Thyroid nodule
.
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Cardiac History: none
.
Percutaneous coronary intervention: [**2150**] with PTCA of the mid
RCA and OM2
.
Pacemaker/ICD placed: none

MEDICATION ON ADMISSION: Aspirin 325 mg daily
Isosorbide dinitrate 20 mg po tid (pt reports as 40mg am, and
20mg pm)
Metoprolol 12.5 mg po bid
Simvastatin 40 mg daily
fluticasone nasal spray
Fluticasone-Salmeterol 250/50 inh [**Hospital1 **]
Albuterol
Glargine 6 u subq daily
Lispro sliding scale
Montelukast 10 mg daily
Calcitriol 0.25 mg po daily
Sevelamer 400 mg po tid -- patient has not been taking this
Tamsulosin 0.4 mg daily
MVI
Polysaccharide Iron Complex 150 mg Capsule [**Hospital1 **]
Loratadine 10 mg daily
Augmentin 500/125 [**Hospital1 **]

ALLERGIES: Gluten

PHYSICAL EXAM: VS: 98.5  128 95/66  29  91%10L
PA 47/24
Gen: WDWN elderly Russian male in NAD, resp or otherwise.
Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP elevated
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: pericardial drain in place. No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored. crackles at lateral
bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominal
bruits.
Ext: No c/c/e. No femoral bruits. arterial and venous access in
right groin.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: None

SOCIAL HISTORY: Born in [**Country 532**], moved to US in [**2150**]. Lives with his wife. Former
organic chemistry professor. He has never smoked. He does not
consume alcohol on a regular basis (1 drink every 2-3 months). 

### Response:
{'Acute idiopathic pericarditis,Acute kidney failure, unspecified,Cellulitis and abscess of leg, except foot,Cardiogenic shock,Acute respiratory failure,Acute on chronic diastolic heart failure,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Cardiac tamponade,Atrial fibrillation,Long-term (current) use of insulin,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Hyperpotassemia,Celiac disease,Anemia in chronic kidney disease,Pure hypercholesterolemia'}
