CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 77 YO gentleman with history of multiple TIAs s/p recetn CEA on
[**4-20**] brought into ED by ambulace for hypoxemia and respiratory
failure. Dr. [**Known lastname **] underwent CEA on [**4-20**] and by accounts had an
uneventful post operative course. By report he developed SOB
yesterday that progressivly worsened overnight. This morning he
was unable to get out of bed secondary to weakness. EMS was
called and by their report he was found supine and purple in
bed. They placed on 15l NRB and O2 Sats only came up to 90%. On
arrival to the ED his VS were notable for RR of 40 and sats in
the 90'2 on 15L. He was awake and alert on arrival with a
relativly clear mental status. He was only able to speak in one
or two word sentences. A CXR demonstrated new onset pulmonary
edema. He has no known pulmonary or cardiac history. He had no
reports of fevers, post op or pre-hospital. He denied cough to
ED staff.
.
In the ED he was initially placed on BiPap and had improvement
in his oxygenation. He was given a sublingual NTG and became
hypotensive, this precluded him receiving nitro GTT. He did not
receive IVF. He was noted to have several apneic episodes while
on BiPAP and was intubated due to respiratory fatigue. The
intubation was complicated by difficult to visualize airways and
he suffered a laceration of his lips. By report there was NO
blood in the ETT.
.
He is currently on FiO2 100 %/Peep 5/Rate 17/TV 600. Sedated on
fentanyl and versed. On 6mcg of dopa with BP 113/68. He has had
minimal UOP. Total UOP 100.
.
His labs are significant for a troponin of 1.13, leukocyotsis
21.6, Anion gap acidosis, Cr of 2.5 (baseline 0.9) and an
elevated lactate (6--->3 with intubation).

MEDICAL HISTORY: -h/o stroke in [**2118**], treated at [**Hospital1 2025**], L MCA territory
-BPH with secondary hematuria
-cystic pancreatic mass, following q2years

MEDICATION ON ADMISSION: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)*
Refills:*0*
4. Vitamin C Oral
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
7. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule,
Ext Release 24 hr(s)* Refills:*2*
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0*
Import Discharge Medications

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ED Admission exam:
Temp: 98.2 HR: 109 BP: 108/77 Resp: 33 O(2)Sat: 91 Low
Constitutional: O2 sat 90% NRB FM; pulse 70s
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
no wheezing; left neck with ecchymosis; no bruit; no puls
mass; JVD on right 5 cm
Chest: bilateral insp rales [**12-25**] way up
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds; no m/r/g
Abdominal: Normal
Extr/Back: Normal
Skin: ecchymosis left neck but no other rashes

FAMILY HISTORY: Brother had MI in 40s, sister has carotid stenosis.

SOCIAL HISTORY: Works at the Mind Body Institute he founded and teaches at HMS.
No tobacco, EtOH, illicits. Lives with wife, he provides care
for his wife and administers her medications.
Acute respiratory failure,Acute myocardial infarction of other anterior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Cardiogenic shock,Acute on chronic systolic heart failure,Acidosis,Cardiac complications, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Retention of urine, unspecified,Atrial fibrillation,Diarrhea,Gross hematuria,Unspecified hemorrhoids with other complication,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Acute respiratry failure,AMI anterior wall, init,Ac kidny fail, tubr necr,Cardiogenic shock,Ac on chr syst hrt fail,Acidosis,Surg compl-heart,BPH w/o urinary obs/LUTS,Crnry athrscl natve vssl,Retention urine NOS,Atrial fibrillation,Diarrhea,Gross hematuria,Hemrrhoid NOS w comp NEC,Hx TIA/stroke w/o resid,Abn react-anastom/graft
Admission Date:  [**2131-4-23**]              Discharge Date:   [**2131-5-3**]

Date of Birth:  [**2054-4-15**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
intubation
central line placement
Cardiac catheterization with no intervention


History of Present Illness:
77 YO gentleman with history of multiple TIAs s/p recetn CEA on
[**4-20**] brought into ED by ambulace for hypoxemia and respiratory
failure. Dr. [**Known lastname **] underwent CEA on [**4-20**] and by accounts had an
uneventful post operative course. By report he developed SOB
yesterday that progressivly worsened overnight. This morning he
was unable to get out of bed secondary to weakness. EMS was
called and by their report he was found supine and purple in
bed. They placed on 15l NRB and O2 Sats only came up to 90%. On
arrival to the ED his VS were notable for RR of 40 and sats in
the 90'2 on 15L. He was awake and alert on arrival with a
relativly clear mental status. He was only able to speak in one
or two word sentences. A CXR demonstrated new onset pulmonary
edema. He has no known pulmonary or cardiac history. He had no
reports of fevers, post op or pre-hospital. He denied cough to
ED staff.
.
In the ED he was initially placed on BiPap and had improvement
in his oxygenation. He was given a sublingual NTG and became
hypotensive, this precluded him receiving nitro GTT. He did not
receive IVF. He was noted to have several apneic episodes while
on BiPAP and was intubated due to respiratory fatigue. The
intubation was complicated by difficult to visualize airways and
he suffered a laceration of his lips. By report there was NO
blood in the ETT.
.
He is currently on FiO2 100 %/Peep 5/Rate 17/TV 600. Sedated on
fentanyl and versed. On 6mcg of dopa with BP 113/68. He has had
minimal UOP. Total UOP 100.
.
His labs are significant for a troponin of 1.13, leukocyotsis
21.6, Anion gap acidosis, Cr of 2.5 (baseline 0.9) and an
elevated lactate (6--->3 with intubation).

Past Medical History:
-h/o stroke in [**2118**], treated at [**Hospital1 2025**], L MCA territory
-BPH with secondary hematuria
-cystic pancreatic mass, following q2years

Social History:
Works at the Mind Body Institute he founded and teaches at HMS.
No tobacco, EtOH, illicits. Lives with wife, he provides care
for his wife and administers her medications.

Family History:
Brother had MI in 40s, sister has carotid stenosis.


Physical Exam:
ED Admission exam:
Temp: 98.2 HR: 109 BP: 108/77 Resp: 33 O(2)Sat: 91 Low
Constitutional: O2 sat 90% NRB FM; pulse 70s
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
no wheezing; left neck with ecchymosis; no bruit; no puls
mass; JVD on right 5 cm
Chest: bilateral insp rales [**12-25**] way up
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds; no m/r/g
Abdominal: Normal
Extr/Back: Normal
Skin: ecchymosis left neck but no other rashes

Physical Exam on Discharge:
VS: 98.2/98.2 67-72 RR 18-20 BP: 125-152/74-76 O2 sat 92-97% RA
I/O: 8 hour 84/425
     24 hour 1130/[**2103**]
TELE: SR, HR 70's
Weight: refused for 2 days
GEN: NAD, sitting comfortably in chair
HEENT: MMM, no conjunctival erythema or scleral icterus
NECK: no JVD; ecchymosis over left CEA site but no fluctuance or
mass
CV: Regular, S1 and S2, no murmur
PULM: lungs CTA throughout
ABDOMEN: nondistended, (+)bowel sounds, nontender
EXTREM: 2+ DP and PT pulses bilaterally, no edema, warm feet
NEURO: alert, oriented x3, answers all questions appropriately


Pertinent Results:
Admission Labs:

[**2131-4-23**] 01:30PM BLOOD WBC-21.6* RBC-4.35* Hgb-13.7* Hct-43.1
MCV-99* MCH-31.4 MCHC-31.7 RDW-13.4 Plt Ct-265
[**2131-4-23**] 01:30PM BLOOD Neuts-90.1* Lymphs-4.9* Monos-4.0 Eos-0.8
Baso-0.3
[**2131-4-23**] 01:30PM BLOOD Glucose-279* UreaN-47* Creat-2.5*# Na-135
K-4.9 Cl-94* HCO3-23 AnGap-23*
[**2131-4-23**] 05:31PM BLOOD ALT-41* AST-152* CK(CPK)-912* AlkPhos-88
TotBili-0.7

Relevant Labs:
[**2131-4-22**] 08:05AM BLOOD proBNP-8203*
[**2131-4-23**] 01:30PM BLOOD CK-MB-40* MB Indx-4.9
[**2131-4-23**] 01:30PM BLOOD cTropnT-1.33*
[**2131-4-23**] 05:31PM BLOOD CK-MB-46* MB Indx-5.0 cTropnT-2.08*
[**2131-4-24**] 12:45AM BLOOD CK-MB-44* MB Indx-5.6 cTropnT-2.96*
[**2131-4-25**] 04:02AM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-4.25*
[**2131-4-26**] 05:27AM BLOOD CK-MB-4 cTropnT-5.38*
[**2131-4-27**] 05:25AM BLOOD CK-MB-2 cTropnT-5.70*
[**2131-4-28**] 03:18AM BLOOD CK-MB-2 cTropnT-5.21*

Imaging/Reports:

Chest x-ray [**2131-4-23**]
Endotracheal tube positioned appropriately.  NG tube appears
also
to be positioned appropriately, though the tip is excluded from
view.  Diffuse pulmonary edema with pleural effusions again
seen.

TTE [**2131-4-23**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with near
akinesis of the distal 2/3rds of the septum, anterior wall,
apex, and distal inferior wall. The remaining segments contract
normally (LVEF = 30 %). No intraventricular thrombus is seen.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#).No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. [Due to acoustic shadowing/suboptimal
image quality, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be quantified. There is an anterior space
which most likely represents a prominent fat pad.

IMPRESSION: Normal left ventricular cavity size with extensiver
regional systolic dysfunction c/w CAD (mid-LAD distribution) or
Takotsubo cardiomyopathy. No definite valvular dysfunction.

Compared with the prior study (images reviewed) of [**2131-4-19**],
the left ventricular wall motion abnormalities are new and c/w
interim ischemia/infarction.

TTE [**2131-4-27**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is
moderately-to-severely depressed (LVEF = 30 %) secondary to
extensive severe hypokinesis/akinesis involving the anterior
septum, anterior free wall, apex, and inferior septum. Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. The mitral valve
leaflets are myxomatous. There is mild posterior leaflet mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared to the prior study of [**2131-4-23**], moderate mitral
regurgitation is now seen.

Renal US:
FINDINGS:  The right kidney measures 12.2 cm and the left kidney
measures 11.4 cm.  A 6 x 6 x 4 mm non-obstructing stone is
present in the right kidney interpolar region.  No left renal
calculus.  No hydronephrosis or mass seen in either kidney.  The
bladder contains a Foley, is minimally distended, and cannot be
assessed.
IMPRESSION:  6-mm nonobstructing right renal stone.  No
hydronephrosis

Cardiac Catheterization [**2131-5-1**]:
1. Selective coronary angiography in this left-dominant system
demonstrated two vessel disease. The LMCA had no
angiographically
apparent disease. The LAD was occluded proximally and filled via

right-to-left collaterals. The LCx was dominant and had mild
disease.
The nondominant RCA was subtotally occluded but provided robust
collaterals to the LAD via an acute marginal.
2. Limited resting hemodynamcis revealed normal systemic
arterial blood
pressure.

FINAL DIAGNOSIS:
1. Two-vessel coronary artery disease.
2. Normal systemic arterial blood pressure.

Dobutamine Stress Test [**2131-5-2**]:
77 yo man presented in respiratory failure secondary
to subacute anterior MI post-op following left carotid
endarterectomy on
[**2131-4-20**], cardiac catheterization revealing 2-vessel CAD and
depressed
LVEF was referred to evaluate for viability in LAD territory.
The
patient was administered 2.5, 5, 10 and 20 mcg/kg/min of
Dobutamine (5
min stages) for a total infusion duration of 20 minutes. No
chest, back,
neck or arm discomforts were reported. No significant ST segment
changes
were noted during the procedure. The rhythm was sinus with rare
isolated
VPBs noted. The heart rate response was appropriate. A blunted
blood
pressure response was noted with the Dobutamine infusion.

IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Blunted
blood pressure response to the Dobutamine infusion. Echo report
sent
separately.

Stress ECHO [**5-2**]:
The patient received intravenous dobutamine in 5 min (low dose
2.5mcg/kg/min) and 3 minute stages (>5mcg/kg/min) to a maximum
of 20 mcg/kg/min. The test was stopped because the viability
protocol was completed. In response to stress, the ECG showed no
diagnostic ST-T wave changes (see exercise report for details).
The blood pressure response to stress was blunted. There was a
normal heart rate response to stress.
.
Resting images were acquired at a heart rate of 72 bpm and a
blood pressure of 136/68 mmHg. These demonstrated regional left
ventricular systolic dysfunction with severe hypokinesis to
akinesis of the septum, anterior wall, mid to distal lateral
wall, apex, and distal inferior wall. The remaining segments
contracted well. (LVEF = 25-30 %). Right ventricular free wall
motion is normal. There is a trivial pericardial effusion.
Doppler demonstrated trace aortic regurgitation and moderate
mitral regurgitation with no aortic stenosis or significant
resting LVOT gradient.
At low dose dobutamine [5mcg/kg/min; heart rate 72 bpm, blood
pressure 134/60 mmHg), there was failure to augment systolic
function of the affected (LAD territory) segments. At mid-dose
dobutamine [5-10 mcg/kg/min; heart rate 74 bpm, blood pressure
130/50 mmHg), there was failure to further augment systolic
function of the affected left ventricular segments. At peak
dobutamine stress [20 mcg/kg/min; heart rate 88 bpm, blood
pressure 128/50 mmHg), no new regional wall motion abnormalities
were identified. Baseline abnormalities persist.

IMPRESSION: No diagnostic ECG changes with 2D echocardiographic
evidence of prior proximal LAD-territory myocardial infarction
without inducible ischemia to dobutamine administration or
evidence of viability of the anterior/septal/apical/distal
inferior wall. The other segments augment appropriately. Trace
aortic regurgitation at rest. Moderate mitral and tricuspid
regurgitation at rest. At least moderate pulmonary hypertension.


Labs on Discharge:

[**2131-5-3**] 04:58AM BLOOD WBC-12.5* RBC-3.48* Hgb-11.1* Hct-33.9*
MCV-98 MCH-31.9 MCHC-32.7 RDW-13.6 Plt Ct-313
[**2131-5-3**] 04:58AM BLOOD Glucose-165* UreaN-32* Creat-1.6* Na-137
K-3.9 Cl-104 HCO3-23 AnGap-14
[**2131-5-1**] 07:40AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.9


Brief Hospital Course:
Dr. [**Known lastname **] is a 77 year old gentleman who presented 2 days s/p
left CEA with new-onset systolic CHF secondary to peri-operative
anterior MI.  His course has been complicated by hypoxic
respiratory failure (resolved/extubated after treatment of CHF),
AFib (s/p cardioversion and Amiodarone), and [**Last Name (un) **] (likely from
hypoperfusion, now resolving).

# CAD/acute MI: Enzymes, EKG and history suggested recent MI
associated with pulmonary edema and need for intubation in the
[**Hospital1 18**] ER. Was on lasix GTT and dopamine transiently in the CCU
and ultimately extubated without difficulty once volume status
optimized. Unclear age or extent of infarct but likley had been
>24 hours prior to admission and so did not complete urgent PCI.
 TTE showing LVEF 30% with Hypokinesis and akinesis of apex.
Troponins peaked at 5.7.  Patient was medically managed.  He had
a diagnosstic cardiac catheterization to assess for lesions that
could be intervened upon.  It showed left-dominant system two
vessel disease (hydrated pre and post cath to avoid [**Last Name (un) **]). The
LMCA had no angiographically apparent disease. The LAD was
occluded proximally and filled via right-to-left collaterals.
The LCx was dominant and had mild disease. The nondominant RCA
was subtotally occluded but provided robust collaterals to the
LAD via an acute marginal.  No intervention was done at that
time.  A dobutamine stress test was obtained to assess for
viability.  This showed no viability, so patient not candidate
for re-catheterization.  Continued home  ASA.  Started on Toprol
50 XL daily, plavix. Patient initially not on RAAS blocker due
to [**Last Name (un) **], but as Cr trended down, started Lisinopril 2.5.  Patient
was seen by representative from the life vest and agreed to use
it on discharge.
.
#. Mild transaminitis: Initially suspicious for drug reaction to
amiodarone or ceftriaxone.  Stopped offending agents.
Transaminitis improved.  On d/c, patient was tolerating statin.

.
# Paroxysmal Afib: Patient was went into atrial fibrillation
with RVR on morning following admission. He was electrically
cardioverted once in the CCU but promptly flipped back in to
Afib with RVR. He was oaeed with amiodarone and converted to NSR
which he remained in for the duration of his stay. The
amiodarone was eventually discontinued prior to discharge for a
mild transaminitis.
.
# [**Last Name (un) **]: Baseline Cr 1.0 but was 2.5 on arrival.  Most likely from
poor perfusion in the setting of decompensated heart failure
however arrived to CCU w/ clot in foley. Changed to 3-way with
CBI. Was never oliguric.  Renal ultrasound showed no signs of
obstruction.  [**Month (only) 116**] have had some component of ATN. Trended Cr,
avoided nephrotoxins, renally dosed meds.  On d/c, Cr was 1.6.
.
# BPH: foley in place. Some pink urine in bag. Urine cultures
were negative x2. Continued Tamsulosin and Finasteride.  Team
was in communication with Dr. [**Last Name (STitle) **], the outpt urologist.
Decided to keep foley in on d/c and Dr. [**Last Name (STitle) **] will d/c it as
outpatient.
.
# s/p CEA: Vascular following. Per Vascular Surgery, there was
no concern for bovine graft infection or hematoma on admission.
But given his initial leukocytosis they wanted to empirically
treat with Abx until it is clear he was never bacteremic.  Blood
cx from [**4-23**] were negative, so d/c'ed abx on [**4-24**].
.
#. Leukocytosis: On admission, Dr. [**Known lastname **] had persistently mild
leukocytosis (WBC [**12-7**]). WBC was trending up prior to d/c after
CEA, and was discharged on empiric Cipro (had foley in place).
Upon initial presentation this admission, WBC was 21.6 but has
persistently been [**12-7**] since then.  Note that he was on
Vanc/Zosyn from admission [**Date range (1) **].  However, here urine culture
negative, initial blood cultures negative, and nothing on
history or physical to suggest PNA.  Loose stools but C.diff
negative.  Vascular believed there was  no bovine CEA graft
infection.  No cellulitis.  His current leukocytosis was likely
related to MI in addition to ongoing stress response.
Antibiotics were d/c'ed on [**4-24**] as above.
.

TRANSITIONS OF CARE:
- Repeat TTE in 1 month or at cardiology followup to determine
whether he needs the life vest/AICD placement
- Repeat LFTs at PCP visit to ensure transaminitis is resolving
- Will have INR and Chem7 checked on Monday after d/c
- Follow up with urology to have foley removed
- Will need WBC trended and if persistently elevated will need
to be worked up as outpatient
- Emergency Contact : [**Name (NI) 4134**] [**Name (NI) **] (wife/HCP) [**Telephone/Fax (1) 101252**]


Medications on Admission:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)*
Refills:*0*
4. Vitamin C Oral
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
7. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule,
Ext Release 24 hr(s)* Refills:*2*
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0*
Import Discharge Medications


Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7 and INR on Monday [**5-7**] with results to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 2010**]
Fax: [**Telephone/Fax (1) 4004**]
ICD 9: 410.01
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
7. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
8. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Metamucil     Powder Sig: Two (2) teaspoons PO once a day as
needed for constipation.
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain: Take 1 tab,
wait 5 min, can take 1 more tab, call 911 if you still have CP.
.
Disp:*25 tab* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Acute systolic congestive heart failure
Myocardial infarction
Acute Kidney Injury
Acute Urinary retention
Transient atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


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

You were admitted to [**Hospital1 18**] due to respiratory failure which was
due to heart failure after peri-operative MI.  You required
intubation and diuresis but were able to be extubated.  Your
stay was complicated by atrial fibrillation (now resolved),
kidney injury due to your heart attack (slowly resolving), and
continued urinary retention (for which you still have a foley
catheter).  Please follow up with your PCP, [**Name10 (NameIs) **], and
Urology (appointments listed below).

Due to the decrease in your EF, you should weigh yourself every
morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3 lbs in 1
day or 5 pounds in 3 days.
You have also been fitted with a Lifevest that will defibrillate
ventricular tachycardia or fibrillation if it occurs.

We made the following changes to your medications:
1. START taking clopidogrel to prevent further thrombus
formation
2. START taking metoprolol to slow your heart rate
3. START taking lisinopril to help with remodeling of your heart
and as an afterload reducer
4. START taking tamsulosin and finasteride to shrink your
prostate
5. INCREASE the atorvastatin to 40 mg daily
6. START taking nitroglycerin tablets as needed for chest pain
7. START taking warfarin to prevent clot formation in your left
ventricle and prevent another stroke.

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: TUESDAY [**2131-5-8**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2131-5-10**] at 2:50 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider.  [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.

Department: CARDIAC SERVICES
When: THURSDAY [**2131-5-31**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2131-5-5**]
{'Acute respiratory failure,Acute myocardial infarction of other anterior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Cardiogenic shock,Acute on chronic systolic heart failure,Acidosis,Cardiac complications, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Retention of urine, unspecified,Atrial fibrillation,Diarrhea,Gross hematuria,Unspecified hemorrhoids with other complication,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: 77 YO gentleman with history of multiple TIAs s/p recetn CEA on
[**4-20**] brought into ED by ambulace for hypoxemia and respiratory
failure. Dr. [**Known lastname **] underwent CEA on [**4-20**] and by accounts had an
uneventful post operative course. By report he developed SOB
yesterday that progressivly worsened overnight. This morning he
was unable to get out of bed secondary to weakness. EMS was
called and by their report he was found supine and purple in
bed. They placed on 15l NRB and O2 Sats only came up to 90%. On
arrival to the ED his VS were notable for RR of 40 and sats in
the 90'2 on 15L. He was awake and alert on arrival with a
relativly clear mental status. He was only able to speak in one
or two word sentences. A CXR demonstrated new onset pulmonary
edema. He has no known pulmonary or cardiac history. He had no
reports of fevers, post op or pre-hospital. He denied cough to
ED staff.
.
In the ED he was initially placed on BiPap and had improvement
in his oxygenation. He was given a sublingual NTG and became
hypotensive, this precluded him receiving nitro GTT. He did not
receive IVF. He was noted to have several apneic episodes while
on BiPAP and was intubated due to respiratory fatigue. The
intubation was complicated by difficult to visualize airways and
he suffered a laceration of his lips. By report there was NO
blood in the ETT.
.
He is currently on FiO2 100 %/Peep 5/Rate 17/TV 600. Sedated on
fentanyl and versed. On 6mcg of dopa with BP 113/68. He has had
minimal UOP. Total UOP 100.
.
His labs are significant for a troponin of 1.13, leukocyotsis
21.6, Anion gap acidosis, Cr of 2.5 (baseline 0.9) and an
elevated lactate (6--->3 with intubation).

MEDICAL HISTORY: -h/o stroke in [**2118**], treated at [**Hospital1 2025**], L MCA territory
-BPH with secondary hematuria
-cystic pancreatic mass, following q2years

MEDICATION ON ADMISSION: 1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*1*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)*
Refills:*0*
4. Vitamin C Oral
5. verapamil 180 mg Tablet Extended Rel 24 hr Sig: 1.5 Tablet
Extended Rel 24 hrs PO once a day.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation. Disp:*60 Capsule(s)*
Refills:*2*
7. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime). Disp:*30 Capsule,
Ext Release 24 hr(s)* Refills:*2*
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0*
Import Discharge Medications

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ED Admission exam:
Temp: 98.2 HR: 109 BP: 108/77 Resp: 33 O(2)Sat: 91 Low
Constitutional: O2 sat 90% NRB FM; pulse 70s
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
no wheezing; left neck with ecchymosis; no bruit; no puls
mass; JVD on right 5 cm
Chest: bilateral insp rales [**12-25**] way up
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds; no m/r/g
Abdominal: Normal
Extr/Back: Normal
Skin: ecchymosis left neck but no other rashes

FAMILY HISTORY: Brother had MI in 40s, sister has carotid stenosis.

SOCIAL HISTORY: Works at the Mind Body Institute he founded and teaches at HMS.
No tobacco, EtOH, illicits. Lives with wife, he provides care
for his wife and administers her medications. 

### Response:
{'Acute respiratory failure,Acute myocardial infarction of other anterior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Cardiogenic shock,Acute on chronic systolic heart failure,Acidosis,Cardiac complications, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Retention of urine, unspecified,Atrial fibrillation,Diarrhea,Gross hematuria,Unspecified hemorrhoids with other complication,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
