CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 77M with h/o CAD, PVD, a fib, on coumadin, recent dx of
Aflutter, c/o left sided chest pain for one week, generalized
weakness, SOB on exertion, increased LE edema. Pt describes
sharp, localized pain on L side of chest near axilla, somewhat
reproduceable, began at around the same time that he fell out of
bed and had to call for nurse to come and get him up. Also has
been SOB on exertion, but pain and dyspnea are independent --
either can occur without the other. SOB has also developed over
past two weeks, always w/ exertion, sometimes only minor
exertion. VNA found him w/ irregular heart rate on morning of
admission, sent him to ED. Got full ASA en route, pain improved
but still present.

MEDICAL HISTORY: Dyslipidemia
Hypertension
Nondisplaced fracture of greater trochanter of left femur
Status post skin graft
Compression fracture of L4 lumbar vertebra
Esophagitis
Depression
Peripheral Edema
Orthostatic Hypotension
Obesity
COLONIC ADENOMA
ANEMIA, UNSPEC
ATRIAL FLUTTER
ESOPHAGEAL ATRESIA/STENOSIS/TE FISTULA - CONGEN
ATRIAL FIBRILLATION
OSTEOARTHRITIS - KNEE, left
PSORIASIS
CELLULITIS (SPECIFY SITE)
PROSTATIC HYPERTROPHY - BENIGN
STASIS ULCER
THROMBOPHLEBITIS/PHLEBITIS OF DEEP VEINS
PERIPHERAL VASCULAR DISEASE
h/o ALCOHOL DEPENDENCE
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

MEDICATION ON ADMISSION: 1. Warfarin 2 mg PO DAILY16
2. Multivitamins 1 TAB PO DAILY
3. Citalopram 20 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY

ALLERGIES: Ancef / Bactrim / latex / doxycycline

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS- T=97.7 BP=127/97 HR=109 RR=16 O2 sat=99%RA
GENERAL- Obese elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK- Supple, no carotid bruits, JVP could not be appreciated w/
pt at 30-degree angle.
CARDIAC- faint heart sounds, tachycardic, regular. No m/r/g
appreciated. No thrills, lifts.
LUNGS- Barrel chest, no chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese NTND. No abdominial bruits.
MS- tender to palpation over L chest near axilla, no tenderness
on right.
EXTREMITIES- No c/c/e.
SKIN- Trigonal area is erythematous, well-demarcated under
pannus, malodorous. Extensive ulceration over [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**],
some w/ crusting, some open and bleeding on exposure. No
purulence, no tenderness or swelling. No heel ulcers. Toes
appear pink, well perfused.
PULSES-
Right: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
Left: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
.
MICU Transfer Exam:
General: Extubated. AOx3
HEENT: PERRL, anicteric sclera, ETT in place, bilateral neck and
upper chest subQ emphysema with crepitus ?????? similar to yesterday.
Right neck dressing c/d/i. JP drain in place.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA on anterior exam, no crackles or wheezing.
Ab: obese, NT/ND, no HSM. Normoactive BS, PEG in place
Ext: Bilateral erythematous plaques over groin, bandaged LE.
Neuro: No focal motor deficits noted.
.
Discharge exam:
VS: Tc 98.5, Tm 98.9, HR 107(97-112), BP 103/66(103-113/58-72),
RR 20, SO2 96%@2L, INS/OUT (600+300+400)/(1550+950) = -1200
GEN: pleasant, NAD, well-developed, well-nourished
HEENT: PERRLA, MMM, poor dentition, tongue has white/brown
material on dorsum, EOMI but with R eye convergence
insufficiency, sclera anicteric, no conjunctival injection
NECK: healing surgical scar with crusted blood at incision site,
no spreading erythema or purulence; no crepitance
PULM: mild crackles [**11-26**] way up on L only
CV: tachycardia, regular rhythm, normal S1/S2, no m/r/g
EXT: b/l leg atrophy (L>R), b/l leg bandages with underlying
ulcerations extending to proximal legs; no edema; dorsalis
pedis, posterior tibial, and radial pulses palpable b/l; PICC
line in L arm with no associated pain or site bleeding/bruising
ABD: G-J tube in place, surgical wound site tenderness but no
spreading erythema or purulence; mild discomfort to deep
palpation in lower abdomen, soft, protuberant, no r/g
MSK:  strength 5+ grossly throughout
NEURO/PSYCH: CN II-XII grossly intact; mood: ??????all right??????,
affect: appropriate

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Pt lives alone, has VNA and home health aid to help with wound
care, ADLs. Former professional puppeteer, widowed in [**2178**].
-Tobacco history: 60 pack-year history, nonsmoker since late
[**2151**].
-ETOH: Former heavy drinker, currently sober
Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hematemesis,Ulcer of lower limb, unspecified,Other digestive system complications,Paralytic ileus,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Candidiasis of skin and nails,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Venous (peripheral) insufficiency, unspecified,Dermatophytosis of groin and perianal area,Depressive disorder, not elsewhere classified,Atherosclerosis of native arteries of the extremities, unspecified,Long-term (current) use of anticoagulants,Personal history of colonic polyps
Atrial fibrillation,Ot pul insuf fol trm/srg,Accidental op laceration,Hematemesis,Ulcer of lower limb NOS,Oth digestv system comp,Paralytic ileus,Acc cut in med care NEC,Abn react-procedure NEC,Abn react-surg proc NEC,Cutaneous candidiasis,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypoxemia,Constipation NOS,Venous insufficiency NOS,Dermatophytosis of groin,Depressive disorder NEC,Athscl extrm ntv art NOS,Long-term use anticoagul,Prsnl hst colonic polyps
Admission Date:  [**2194-6-16**]              Discharge Date:   [**2194-6-27**]

Date of Birth:  [**2116-11-28**]             Sex:   M

Service: MEDICINE

Allergies:
Ancef / Bactrim / latex / doxycycline

Attending:[**Last Name (NamePattern1) 13159**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
- TEE
- Direct laryngoscopy and right neck exploration with closure of
cervical esophageal laceration and placement of drain.- PICC
line placement
- Arterial Line
- Operative G-J tube placement
- Intubation and Mechanical Ventilation

History of Present Illness:
77M with h/o CAD, PVD, a fib, on coumadin, recent dx of
Aflutter, c/o left sided chest pain for one week, generalized
weakness, SOB on exertion, increased LE edema. Pt describes
sharp, localized pain on L side of chest near axilla, somewhat
reproduceable, began at around the same time that he fell out of
bed and had to call for nurse to come and get him up. Also has
been SOB on exertion, but pain and dyspnea are independent --
either can occur without the other. SOB has also developed over
past two weeks, always w/ exertion, sometimes only minor
exertion. VNA found him w/ irregular heart rate on morning of
admission, sent him to ED. Got full ASA en route, pain improved
but still present.

Past Medical History:
Dyslipidemia
Hypertension
Nondisplaced fracture of greater trochanter of left femur
Status post skin graft
Compression fracture of L4 lumbar vertebra
Esophagitis
Depression
Peripheral Edema
Orthostatic Hypotension
Obesity
COLONIC ADENOMA
ANEMIA, UNSPEC
ATRIAL FLUTTER
ESOPHAGEAL ATRESIA/STENOSIS/TE FISTULA - CONGEN
ATRIAL FIBRILLATION
OSTEOARTHRITIS - KNEE, left
PSORIASIS
CELLULITIS (SPECIFY SITE)
PROSTATIC HYPERTROPHY - BENIGN
STASIS ULCER
THROMBOPHLEBITIS/PHLEBITIS OF DEEP VEINS
PERIPHERAL VASCULAR DISEASE
h/o ALCOHOL DEPENDENCE
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

Social History:
Pt lives alone, has VNA and home health aid to help with wound
care, ADLs. Former professional puppeteer, widowed in [**2178**].
-Tobacco history: 60 pack-year history, nonsmoker since late
[**2151**].
-ETOH: Former heavy drinker, currently sober

Family History:
Noncontributory

Physical Exam:
ADMISSION PHYSICAL EXAM
VS- T=97.7 BP=127/97 HR=109 RR=16 O2 sat=99%RA
GENERAL- Obese elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK- Supple, no carotid bruits, JVP could not be appreciated w/
pt at 30-degree angle.
CARDIAC- faint heart sounds, tachycardic, regular. No m/r/g
appreciated. No thrills, lifts.
LUNGS- Barrel chest, no chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese NTND. No abdominial bruits.
MS- tender to palpation over L chest near axilla, no tenderness
on right.
EXTREMITIES- No c/c/e.
SKIN- Trigonal area is erythematous, well-demarcated under
pannus, malodorous. Extensive ulceration over [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**],
some w/ crusting, some open and bleeding on exposure. No
purulence, no tenderness or swelling. No heel ulcers. Toes
appear pink, well perfused.
PULSES-
Right: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
Left: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
.
MICU Transfer Exam:
General: Extubated. AOx3
HEENT: PERRL, anicteric sclera, ETT in place, bilateral neck and
upper chest subQ emphysema with crepitus ?????? similar to yesterday.
Right neck dressing c/d/i. JP drain in place.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA on anterior exam, no crackles or wheezing.
Ab: obese, NT/ND, no HSM. Normoactive BS, PEG in place
Ext: Bilateral erythematous plaques over groin, bandaged LE.
Neuro: No focal motor deficits noted.
.
Discharge exam:
VS: Tc 98.5, Tm 98.9, HR 107(97-112), BP 103/66(103-113/58-72),
RR 20, SO2 96%@2L, INS/OUT (600+300+400)/(1550+950) = -1200
GEN: pleasant, NAD, well-developed, well-nourished
HEENT: PERRLA, MMM, poor dentition, tongue has white/brown
material on dorsum, EOMI but with R eye convergence
insufficiency, sclera anicteric, no conjunctival injection
NECK: healing surgical scar with crusted blood at incision site,
no spreading erythema or purulence; no crepitance
PULM: mild crackles [**11-26**] way up on L only
CV: tachycardia, regular rhythm, normal S1/S2, no m/r/g
EXT: b/l leg atrophy (L>R), b/l leg bandages with underlying
ulcerations extending to proximal legs; no edema; dorsalis
pedis, posterior tibial, and radial pulses palpable b/l; PICC
line in L arm with no associated pain or site bleeding/bruising
ABD: G-J tube in place, surgical wound site tenderness but no
spreading erythema or purulence; mild discomfort to deep
palpation in lower abdomen, soft, protuberant, no r/g
MSK:  strength 5+ grossly throughout
NEURO/PSYCH: CN II-XII grossly intact; mood: ??????all right??????,
affect: appropriate


Pertinent Results:
ADMISSION LABS:
[**2194-6-16**] 12:30PM BLOOD WBC-4.9 RBC-3.93* Hgb-11.6* Hct-35.8*
MCV-91 MCH-29.4 MCHC-32.3 RDW-15.8* Plt Ct-258
[**2194-6-16**] 12:30PM BLOOD Neuts-62.8 Lymphs-24.7 Monos-6.0 Eos-5.1*
Baso-1.4
[**2194-6-16**] 12:30PM BLOOD PT-43.2* PTT-53.2* INR(PT)-4.3*
[**2194-6-16**] 12:30PM BLOOD Glucose-95 UreaN-21* Creat-0.9 Na-141
K-4.3 Cl-106 HCO3-29 AnGap-10
[**2194-6-16**] 08:55PM BLOOD CK(CPK)-41*
[**2194-6-17**] 06:05AM BLOOD WBC-4.8 RBC-3.84* Hgb-11.4* Hct-35.4*
MCV-92 MCH-29.8 MCHC-32.3 RDW-15.8* Plt Ct-251
[**2194-6-17**] 11:31PM BLOOD WBC-5.6 RBC-3.72* Hgb-11.0* Hct-34.0*
MCV-91 MCH-29.7 MCHC-32.5 RDW-15.6* Plt Ct-260
[**2194-6-18**] 05:05AM BLOOD WBC-5.1 RBC-3.88* Hgb-11.3* Hct-35.6*
MCV-92 MCH-29.1 MCHC-31.8 RDW-15.8* Plt Ct-260
[**2194-6-18**] 02:52PM BLOOD WBC-8.3# RBC-4.13* Hgb-12.3* Hct-37.8*
MCV-92 MCH-29.7 MCHC-32.5 RDW-15.7* Plt Ct-246
[**2194-6-19**] 03:31AM BLOOD WBC-9.5 RBC-3.48* Hgb-10.2* Hct-31.3*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.6* Plt Ct-203
[**2194-6-19**] 07:47AM BLOOD Hct-30.7*
[**2194-6-19**] 02:43PM BLOOD Hct-31.8*
[**2194-6-20**] 02:45AM BLOOD WBC-9.6 RBC-3.20* Hgb-9.4* Hct-29.2*
MCV-91 MCH-29.4 MCHC-32.2 RDW-15.8* Plt Ct-192
[**2194-6-16**] 12:30PM BLOOD PT-43.2* PTT-53.2* INR(PT)-4.3*
[**2194-6-18**] 05:05AM BLOOD PT-34.1* PTT-47.6* INR(PT)-3.3*
[**2194-6-20**] 02:45AM BLOOD PT-33.6* PTT-42.2* INR(PT)-3.3*
[**2194-6-20**] 10:40AM BLOOD PT-22.9* INR(PT)-2.2*
[**2194-6-18**] 07:11PM BLOOD Type-ART pO2-129* pCO2-50* pH-7.34*
calTCO2-28 Base XS-0
[**2194-6-19**] 02:52AM BLOOD Type-ART Temp-36.7 Rates-18/1 Tidal V-500
FiO2-60 pO2-182* pCO2-43 pH-7.42 calTCO2-29 Base XS-3
-ASSIST/CON Intubat-INTUBATED
[**2194-6-19**] 08:07AM BLOOD Type-ART Temp-36.5 pO2-124* pCO2-42
pH-7.38 calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2194-6-19**] 02:49PM BLOOD Type-ART Temp-36.6 pO2-111* pCO2-46*
pH-7.33* calTCO2-25 Base XS--1 Intubat-INTUBATED
.
EKG [**2194-6-16**]:
Underlying rhythm is likely atrial flutter with rapid
ventricular response.
Left anterior fascicular block. Compared to the previous tracing
of [**2192-12-28**]
atrial flutter is new and Q-T interval is now shorter.
.
TEE [**2194-6-18**]:
GENERAL COMMENTS: Written informed consent was obtained from the
patient. A TEE was performed in the location listed above. I
certify I was present in compliance with HCFA regulations. The
patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the
procedure. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was under general
anesthesia throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The posterior pharynx was
anesthetized with 2% viscous lidocaine. No glycopyrrolate was
administered. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. Image quality was
suboptimald - poor esophageal contact.
Conclusions: [**Name2 (NI) **] thrombus/mass is seen in the body of the left
atrium. No mass or thrombus is seen in the right atrium or right
atrial appendage. Unable to visualize the LAA due to poor image
quality.
.
CT Chest [**2194-6-18**]:
IMPRESSION:
1. Extensive subcutaneous air in the soft tissues of the neck
and anterior
posterior chest wall extending into the mediastinum to the level
of the
carina. Suspected site of possible esophageal perforation is
most likely in the upper to mid esophagus given the distribution
of air, although the
definitive site cannot be delineated on this study.  No large
hematoma.
2. Atelectasis at the lung bases.
3. Hypodense lesions within the liver which are most likely
cysts.
.
CXR [**2194-6-19**]:
FINDINGS: In comparison with the study of [**6-18**], there is
increasing
opacification at both bases with poor definition of the
hemidiaphragms.  This suggests increasing layering pleural
effusions with compressive atelectasis. Subcutaneous emphysema
is essentially unchanged. Mild elevation of pulmonary venous
pressure is probably present.
.
CXR [**2194-6-25**]:
IMPRESSION:  No significant change since prior study.  Mild
pulmonary edema and possible small bilateral pleural effusions.
.
Gastrograffin Esophageal Swallow Study [**2194-6-25**]:
Surgical staples and a drain with surrounding suture material
were
noted in the right upper thorax. No subcutaenous air is
identified. In a semi-upright position, the patient was
administered multiple swallows of contrast. On images 11 through
20, a small drop of contrast is seen
overlying the left clavicle outside of the expected region of
the esophagus. This was suspected to be outside of the patient,
which was confirmed with physical exam, and disappeared after
cleaning the patient. On subsequent swallows, in the frontal and
slightly obliqued positions, there is no evidence of leak in the
hypopharynx and upper esophagus. Thin barium was not
administered per request of the ENT team.
IMPRESSION: No evidence of upper esophageal leak with Optiray
oral contrast
.
DISCHARGE LABS
[**2194-6-27**] 06:09AM BLOOD WBC-6.6 RBC-3.30* Hgb-9.6* Hct-29.8*
MCV-90 MCH-29.1 MCHC-32.3 RDW-15.2 Plt Ct-330
[**2194-6-27**] 06:09AM BLOOD Plt Ct-330
[**2194-6-27**] 06:09AM BLOOD PT-14.7* PTT-30.9 INR(PT)-1.4*
[**2194-6-27**] 06:09AM BLOOD Glucose-92 UreaN-19 Creat-0.6 Na-140
K-4.3 Cl-103 HCO3-31 AnGap-10
[**2194-6-27**] 06:09AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2

Brief Hospital Course:
77M with h/o CAD, PVD, afib on coumadin c/o left sided chest
pain for one week, SOB on exertion and at rest, increased LE
edema, suspicious for ACS vs. demand ischemia [**12-26**] heart rate.
.
#Chest pain. Pt w/ multiple risk factors, admitted for lateral
L-sided chest pain. Trops neg, EKG showed no acute changes. Pain
not associated with activity, also occurs with or without SOB.
On further investigation his pain is reproduceable: pt was
tender on his L chest wall near his axilla. Pt endorsed a fall
from his bed that required his nurse to get him up, pt reports
pain started at about this time. Likely that at least some
portion of his pain was musculoskeletal in nature; also possible
is pain secondary to demand from his high heart rate.
.
#Aflutter. Pt was admitted for SOB and chest pain, r/o for MI
with neg trops and EKG as above. EKG and tele both showed
a-flutter with rapid ventricular response. Judged likely that
symptoms were caused by his arrhythmia. EP cards consulted
regarding possible ablation; pt deemed an appropriate candidate
in principle, but procedure not possible until pt clears an
intertrigonal candidal infection. Pt given metoprolol for rate
control with no effect on rate. He was prepped for cardioversion
as a bridging measure prior to ablation. TEE was not able to be
passed blindly and was done with laryngoscopy.  Poor images were
obtained and cardioversion was aborted.  On withdrawal of the
scope, blood was seen and concern for esophageal injury.  CXR
revealed subcutaneous air in the neck with rapid progression.
Patient was transferred to MICU for close monitoring with
Thoracics and ENT consulted for managment of esophageal
perforation.  Plan for a flutter was to continue amiodarone and
metoprolol.
.
MICU COURSE:
# Esophageal Perforation: Upon arrival to MICU, patient was
intubated for airway protection. ENT evaluated patient who
performed a direct laryngoscopy which revealed esophageal
performation. Patient was taken to the OR for repair and
returned to MICU for post-operative monitoring. Patient was
initially started on vancomycin, clindamycin, ciprofloxacin
however was changed to vancomycin/meropenem given persistent
hypotension (see hypotension). Patient was ultimately taken for
GJ tube placement on [**2194-6-20**] for nutrition while esophagus
healed. Patient was subsequently extubated on [**6-20**]. Patient will
need speech and swallow evaluation at direction of ENT and
thoracics.
.
# Hypotension: After perforation and upon intubation, patient
was found to be hypotensive with SBPs 80s-90s. There was initial
concern for sedation induced hypotension, however patient
remained hypotensive after removal of sedation. Patient was
initially started on vancomycin, ciprofloxacin, and clindamycin
however after persistent hypotension patient was changed to
vancomycin and meropenem. After starting meropenem, hypotension
resolved. Of note, on admission note, patient was on
fludrocortisone for orthostatic hypotension. However per PCP he
was not taking it. Adrenal Insufficency was thus ruled with a
normal cosyntropin stimulation test. On transfer BPs were
restored.
.
# Atrial Flutter: Patient remained in atrial flutter while in
MICU. Initially held po medication given esophageal performation
then restarted on amiodarone and metoprolol. Patient was
restarted on warfain without bridge post-operatively.
.
SECOND MICU COURSE:
See above for chronic medical issues.
.
# Hematemesis: Pt transferred back to MICU on [**2194-6-23**] for
hematemesis. He was hemodyanamically stable with stable Hct.
Emesis consistent with coffee ground. He was continued on
Pantoprazole 40mg [**Hospital1 **] IV. No NG lavage was done given recent
esophageal rupture and surgery. Continued Vanc and Meropenem and
repeated CXR which showed resolution of air in the neck and soft
tissues. ENT did not think sx likely [**12-26**] surgical repair but
will cont to follow. Pt remained stable so was called out the
next morning.
.
#Hypoxemia- mild oxygen requirement at 2LNC. Some mild pulm
edema on imaging. Also has a RML consolidation which could
represent aspiration vs. pneumonia especially given he has brown
sputum production. He was stable/afebrile on Vanc and meropenem
which were continued. He responded well to Lasix IV prior to
MICU transfer, and given persisting crackles up to mid lung
bases with mild JVD he was given another 20mg IV lasix. Dry
weight per patient is 238Ibs and currently was 246Ibs. Still on
2L NC on transfer out of MICU...
.
# Pneumomediastinum/esophageal repair - Pt s/p neck exploration
w/ ENT with repair of multiple perforations. Wound was clean and
dry w/o erythema, surrounding crepitus. JP draining clear fluid.
ENT and Thoracic Surgery following.
.
#Constipation- The patient had not passed any stool for more
than 1 week. He denied any abdominal pain, no tenderness to
palp. passing flatus and therefore suspicion for obstruction
low. Could be ileus though none seen on KUB today. aggressive
bowel med given
.
# A flutter/A fib - RVR to 160s, 140s on the [**Hospital1 **]. BPs remained
stable. 5mg IV metoprolol given prior to MICU stay to reduce
rate to ~110. Per cards recs, amiodarone reduced and metoprolol
increased, HR was atrial fib 110-120 at the time of transfer out
of MICU....
.
# Candidal Rash - The patient has extensive intertrigonal
candidal infection. Per wound care recs, will treat with
antifungal critic aid.
.
# Venous status dermatitis - multiple open sores on legs
bilaterally. Seen by wound care and said to be improving.  cont
Betamethasone Dipro 0.05% Cream, Adaptic and Kerlix daily, wound
gel to wound beds to facilitate autolytic debridement
.
MEDICINE WARDS COURSE:
# Hematemesis: The patient was transferred to the wards on
lansoprazole for an episode of hematemesis that was thought to
be unrelated to the patient's esophageal tear per ENT. He was
continued on his lansoprazole with no further incidents.
.
# Hypoxemia- mild oxygen requirement at 2LNC. Some mild pulm
edema on imaging. He was stable/afebrile on Vanc and meropenem
which were continued (notably, these had been ordered for
mediastinitis). He was diuresed on two occasions with good
results and subsequent improvement of the mild bibasilar rales
that were noted pre-diuresis. Post-diuresis, some rales did
remain. His oxygen requirement was low and he will leave the
hospital on 2L NC which can be weaned at rehab. He should be
given 20mg PO lasix daily prn for diuresis as needed.
.
# Pneumomediastinum/esophageal repair - Pt s/p neck exploration
w/ ENT with repair of multiple perforations. Wound was clean and
dry w/o erythema, surrounding crepitus. JP drain was removed.
Esophageal gastrograffin swallow study revealed no esophageal
leakage and patient's diet was advanced to pureed foods with
supplemental tube feeds until he follows up with ENT. Patient is
being treated with vancomycin and meropenem through [**2194-7-1**].
.
# A flutter/A fib - There was a question of whether he was in
atrial flutter vs. atrial tachycardia from a low atrial focus
with 2:1 conduction. The latter was thought to be more likely
the case according to electrophysiology. His heart rate remained
elevated in the 100s and 110s on admission to the general
medical floor where his metoprolol dose was increased to 37.5
[**Hospital1 **]. He remained at approximately 100/minute with no episodes of
RVR or hemodynamic instability. The patient was restarted on his
warfarin, goal INR [**12-27**]. Patient has been receiving 3mg daily
though INR is still subtherapeutic (INR was 1.4 on day of
discharge). Recommend increasing warfarin to 4mg daily and
monitoring INR closely.
.
# Candidal Rash - The patient has extensive intertrigonal
candidal infection. He was treated with a topical miconazole
powder.
.
# Venous status dermatitis - multiple open sores on legs
bilaterally. Seen by wound care and improving. The patient did
well on bethasone Dipro 0.05% Cream, Adaptic and Kerlix daily,
and wound gel to wound beds to facilitate autolytic debridement

.
TRANSITIONAL ISSUES
# WARFARIN DOSING: INR should be checked next on [**2194-6-28**] and
adjusted to a goal INR of [**12-27**].

# VANCOMYCIN DOSING: due to high trough, dose on [**2194-6-26**] was held
and pharmacy was consulted. They recommended changing his dose
from 1000 mg q8 hours to 1250 q12 hours.

# DIURESIS: The patient should be given 20mg PO furosemide on
[**6-28**] and [**2194-6-29**]. After that, the rehab physician may decide
whether or not his volume status dictates a further need for
diuresis.

# HYPODENSE HEPATIC LESION: This should be followed-up on an
outpatient basis with an ultrasound.

Medications on Admission:
1. Warfarin 2 mg PO DAILY16
2. Multivitamins 1 TAB PO DAILY
3. Citalopram 20 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY


Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Warfarin 4 mg PO DAILY16
your INRs will be followed closely and your dose possibly
adjusted to achieve goal INR [**12-27**]
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
8. Meropenem 500 mg IV Q6H
9. Metoprolol Tartrate 37.5 mg PO BID
hold for HR<60 and sbp<90
10. Miconazole Powder 2% 1 Appl TP TID:PRN cutaneous fungus
11. Nystatin Oral Suspension 5 mL PO QID:PRN [**Female First Name (un) **]
swish and spit
12. Ondansetron 8 mg IV Q8H:PRN nausea
13. OxycoDONE (Immediate Release)  2.5-5 mg PO Q4H:PRN pain
hold for rr<12 and sedation. try tylenol first
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 1 TAB PO BID:PRN constipation
16. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
19. Ferrous Sulfate 325 mg PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Fludrocortisone Acetate 0.1 mg PO DAILY
22. Vancomycin 1250 mg IV Q 12H
please draw next trough on [**2194-6-29**] AM.
23. Furosemide 20 mg PO DAILY
Please give for [**2194-6-28**] and [**2194-6-29**] then re-assess the need for
further diuresis.


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]

Discharge Diagnosis:
Primary diagnosis: atrial fibrillation
Secondary diagnosis: esophageal tear


Discharge Condition:

Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you while you were hospitalized
at the [**Hospital1 **]. As you know, you were admitted
with chest pain and found to have an irregular heart rate.
Unfortunately we were not able to put a catheter into your
arteries because of fungus on your skin and we had to put a
probe into your stomach. This procedure was complicated by a
tear in your esophagus which required emergency surgery and
antibiotics. You did very well and the repair was assessed and
found to be intact, allowing you to eat pureed food. You should
not eat any non-pureed food until your ENT surgeon says that it
is safe.

You are on several new medications - please see the sheet
attached for further details.

Followup Instructions:
Cardiology Appointment:
-WITH WHOM?: [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) 2564**] (Dr. [**First Name (STitle) **] [**Name (STitle) 89565**] nurse
practitioner)
-WHERE?: [**Hospital **] Medical [**Hospital1 **] Associates at [**Location (un) **] ([**Location (un) 75527**], [**Location (un) 86**], [**Numeric Identifier 718**])
-WHEN?: [**2194-7-16**] at 3:00 P.M.

Name: [**Last Name (LF) **], [**First Name3 (LF) **] V. MD
Location: [**Doctor Last Name **] & [**Doctor Last Name 3880**] LLC
Address: [**Location (un) 3881**], [**Apartment Address(1) 3882**], [**Location (un) **],[**Numeric Identifier 3883**]
Phone: [**Telephone/Fax (1) 2349**]
Appt:  [**Last Name (LF) 2974**], [**7-4**] at 10:45am
***Please arrive 20 mins early to this appt to fill out some
necessary paperwork.

Department: THORACIC SURGERY
When: THURSDAY [**2194-7-10**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15855**], MD [**Telephone/Fax (1) 2348**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hematemesis,Ulcer of lower limb, unspecified,Other digestive system complications,Paralytic ileus,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Candidiasis of skin and nails,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Venous (peripheral) insufficiency, unspecified,Dermatophytosis of groin and perianal area,Depressive disorder, not elsewhere classified,Atherosclerosis of native arteries of the extremities, unspecified,Long-term (current) use of anticoagulants,Personal history of colonic polyps'}


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: 77M with h/o CAD, PVD, a fib, on coumadin, recent dx of
Aflutter, c/o left sided chest pain for one week, generalized
weakness, SOB on exertion, increased LE edema. Pt describes
sharp, localized pain on L side of chest near axilla, somewhat
reproduceable, began at around the same time that he fell out of
bed and had to call for nurse to come and get him up. Also has
been SOB on exertion, but pain and dyspnea are independent --
either can occur without the other. SOB has also developed over
past two weeks, always w/ exertion, sometimes only minor
exertion. VNA found him w/ irregular heart rate on morning of
admission, sent him to ED. Got full ASA en route, pain improved
but still present.

MEDICAL HISTORY: Dyslipidemia
Hypertension
Nondisplaced fracture of greater trochanter of left femur
Status post skin graft
Compression fracture of L4 lumbar vertebra
Esophagitis
Depression
Peripheral Edema
Orthostatic Hypotension
Obesity
COLONIC ADENOMA
ANEMIA, UNSPEC
ATRIAL FLUTTER
ESOPHAGEAL ATRESIA/STENOSIS/TE FISTULA - CONGEN
ATRIAL FIBRILLATION
OSTEOARTHRITIS - KNEE, left
PSORIASIS
CELLULITIS (SPECIFY SITE)
PROSTATIC HYPERTROPHY - BENIGN
STASIS ULCER
THROMBOPHLEBITIS/PHLEBITIS OF DEEP VEINS
PERIPHERAL VASCULAR DISEASE
h/o ALCOHOL DEPENDENCE
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA

MEDICATION ON ADMISSION: 1. Warfarin 2 mg PO DAILY16
2. Multivitamins 1 TAB PO DAILY
3. Citalopram 20 mg PO DAILY
4. Betamethasone Dipro 0.05% Cream 1 Appl TP [**Hospital1 **]
Apply to venous ulcers
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. Amiodarone 200 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY

ALLERGIES: Ancef / Bactrim / latex / doxycycline

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
VS- T=97.7 BP=127/97 HR=109 RR=16 O2 sat=99%RA
GENERAL- Obese elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK- Supple, no carotid bruits, JVP could not be appreciated w/
pt at 30-degree angle.
CARDIAC- faint heart sounds, tachycardic, regular. No m/r/g
appreciated. No thrills, lifts.
LUNGS- Barrel chest, no chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN- Soft, obese NTND. No abdominial bruits.
MS- tender to palpation over L chest near axilla, no tenderness
on right.
EXTREMITIES- No c/c/e.
SKIN- Trigonal area is erythematous, well-demarcated under
pannus, malodorous. Extensive ulceration over [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**],
some w/ crusting, some open and bleeding on exposure. No
purulence, no tenderness or swelling. No heel ulcers. Toes
appear pink, well perfused.
PULSES-
Right: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
Left: Carotid 1+ Femoral 2+ Radial 1+ DP 2+
.
MICU Transfer Exam:
General: Extubated. AOx3
HEENT: PERRL, anicteric sclera, ETT in place, bilateral neck and
upper chest subQ emphysema with crepitus ?????? similar to yesterday.
Right neck dressing c/d/i. JP drain in place.
CV: S1S2 RRR w/o m/r/g??????s.
Lungs: CTA on anterior exam, no crackles or wheezing.
Ab: obese, NT/ND, no HSM. Normoactive BS, PEG in place
Ext: Bilateral erythematous plaques over groin, bandaged LE.
Neuro: No focal motor deficits noted.
.
Discharge exam:
VS: Tc 98.5, Tm 98.9, HR 107(97-112), BP 103/66(103-113/58-72),
RR 20, SO2 96%@2L, INS/OUT (600+300+400)/(1550+950) = -1200
GEN: pleasant, NAD, well-developed, well-nourished
HEENT: PERRLA, MMM, poor dentition, tongue has white/brown
material on dorsum, EOMI but with R eye convergence
insufficiency, sclera anicteric, no conjunctival injection
NECK: healing surgical scar with crusted blood at incision site,
no spreading erythema or purulence; no crepitance
PULM: mild crackles [**11-26**] way up on L only
CV: tachycardia, regular rhythm, normal S1/S2, no m/r/g
EXT: b/l leg atrophy (L>R), b/l leg bandages with underlying
ulcerations extending to proximal legs; no edema; dorsalis
pedis, posterior tibial, and radial pulses palpable b/l; PICC
line in L arm with no associated pain or site bleeding/bruising
ABD: G-J tube in place, surgical wound site tenderness but no
spreading erythema or purulence; mild discomfort to deep
palpation in lower abdomen, soft, protuberant, no r/g
MSK:  strength 5+ grossly throughout
NEURO/PSYCH: CN II-XII grossly intact; mood: ??????all right??????,
affect: appropriate

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Pt lives alone, has VNA and home health aid to help with wound
care, ADLs. Former professional puppeteer, widowed in [**2178**].
-Tobacco history: 60 pack-year history, nonsmoker since late
[**2151**].
-ETOH: Former heavy drinker, currently sober 

### Response:
{'Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hematemesis,Ulcer of lower limb, unspecified,Other digestive system complications,Paralytic ileus,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Candidiasis of skin and nails,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypoxemia,Constipation, unspecified,Venous (peripheral) insufficiency, unspecified,Dermatophytosis of groin and perianal area,Depressive disorder, not elsewhere classified,Atherosclerosis of native arteries of the extremities, unspecified,Long-term (current) use of anticoagulants,Personal history of colonic polyps'}
