CHIEF COMPLAINT: progressive dyspnea

PRESENT ILLNESS: Mrs. [**Known lastname 111334**] is a 56 year old woman with a history of severe
dilated cardiomyopathy with an EF of [**10-24**]% (?viral vs
post-partum) s/p ICD placement who was admitted on [**2112-2-23**] for
severe shortness of breath and PND, presumably due to worsening
congestive heart failure. Given the lack of edema or hypoxia,
the patient was continued on her home regimen fo torsemide 30mg
PO QAM and 10mg PO QPM. Notable findings during her stay
included a BNP >4000 (baseline of 1000), trigger for severe
dyspnea/orthopnea, and an echo that showed profoundly worsened
EF now down to 5% from 10-15%, with severe dilation of the LV.
At the behest of her cardiologist, Dr. [**First Name (STitle) 437**], she underwent a
right heart cath with plans for a trial of milrinone therapy.
RHC revealed markedly elevated left and right heart filling
pressures that significantly improved with milrinone infusion.
If this milrinone trial fails, she would likely be transferred
to [**Hospital1 3278**] for a heart transplant evaluation.
.
On arrival to the CCU, the patient subjectively felt much better
after milrinone infusion. She had by that point made nearly
700cc of urine.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- Idiopathic vs post partum cardiomyopathy atleast since [**2092**],
EF of [**10-24**]%
- 64 year old female with post-partum dilated cardiomyopathy s/p

MEDICATION ON ADMISSION: Active Medication list as of [**2112-2-23**]:

ALLERGIES: Morphine Sulfate / Pronestyl / Quinidine-Quinine Analogues /
Mexiletine / Captopril / Sulfa (Sulfonamide Antibiotics) / Latex
/ Nitrofurantoin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 97.8 HR 90 BP 95/63 RR 25 O2 95%RA
GENERAL: Chronically ill appearing woman in NAD, AOx3 and
appropriate but mildly drowsy
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father died suddenly at age 74. She reports he may have had a
heart attack and had diabetes near the end of his life. Mother
is alive and fairly healthy.

SOCIAL HISTORY: [**Known firstname **] is married, lives with her husband and has two daughters.
She smoked cigarettes in her 20s and has not smoked tobacco
since. Occasional wine.
Acute on chronic systolic heart failure,Cellulitis and abscess of upper arm and forearm,Other primary cardiomyopathies,Drug-induced delirium,Other vascular complications of medical care, not elsewhere classified,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Candidiasis of vulva and vagina,Automatic implantable cardiac defibrillator in situ,Other iatrogenic hypotension,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Ac on chr syst hrt fail,Cellulitis of arm,Prim cardiomyopathy NEC,Drug-induced delirium,Vasc comp med care NEC,Chr pulmon heart dis NEC,Asthma NOS,Depressive disorder NEC,Anxiety state NOS,Candidal vulvovaginitis,Status autm crd dfbrltr,Iatrogenc hypotnsion NEC,Adv eff parasympatholytc,Cardiac dysrhythmias NEC,Phlbts sprfc vn up extrm,Abn react-procedure NEC
Admission Date:  [**2112-2-23**]              Discharge Date:   [**2112-3-1**]

Date of Birth:  [**2056-1-27**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine Sulfate / Pronestyl / Quinidine-Quinine Analogues /
Mexiletine / Captopril / Sulfa (Sulfonamide Antibiotics) / Latex
/ Nitrofurantoin

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

Major Surgical or Invasive Procedure:
right heart cath
PICC placement

History of Present Illness:
Mrs. [**Known lastname 111334**] is a 56 year old woman with a history of severe
dilated cardiomyopathy with an EF of [**10-24**]% (?viral vs
post-partum) s/p ICD placement who was admitted on [**2112-2-23**] for
severe shortness of breath and PND, presumably due to worsening
congestive heart failure. Given the lack of edema or hypoxia,
the patient was continued on her home regimen fo torsemide 30mg
PO QAM and 10mg PO QPM. Notable findings during her stay
included a BNP >4000 (baseline of 1000), trigger for severe
dyspnea/orthopnea, and an echo that showed profoundly worsened
EF now down to 5% from 10-15%, with severe dilation of the LV.
At the behest of her cardiologist, Dr. [**First Name (STitle) 437**], she underwent a
right heart cath with plans for a trial of milrinone therapy.
RHC revealed markedly elevated left and right heart filling
pressures that significantly improved with milrinone infusion.
If this milrinone trial fails, she would likely be transferred
to [**Hospital1 3278**] for a heart transplant evaluation.
.
On arrival to the CCU, the patient subjectively felt much better
after milrinone infusion. She had by that point made nearly
700cc of urine.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- Idiopathic vs post partum cardiomyopathy atleast since [**2092**],
EF of [**10-24**]%
- 64 year old female with post-partum dilated cardiomyopathy s/p

abdominal ICD implantation for NSVT and inducible VT in EP study

in [**2092**]. She had an abdominal ICD generator change on [**2096-2-8**].

In [**4-/2098**] she had abdominal ICD explantation and lead capping
due to discomfort. She had first transvenous ICD implant on
[**2098-5-29**] in the L pectoral region and had a device change
[**2103-3-7**]. Implantation of a [**Company 1543**] Secura VR Single Chamber

ICD in [**2108-9-14**].
3. OTHER PAST MEDICAL HISTORY:
- Incidental finding noted on chest CT scan of a 6 mm nodule,
mild restriction on PFTs
- status post cholecystectomy, status post appendectomy, two
C-sections
- remote asthma and multiple allergies
- anxiety
- ovarian cysts
- Lyme disease seeing specialists in [**State 531**].

Social History:
[**Known firstname **] is married, lives with her husband and has two daughters.
She smoked cigarettes in her 20s and has not smoked tobacco
since. Occasional wine.


Family History:
Father died suddenly at age 74. She reports he may have had a
heart attack and had diabetes near the end of his life. Mother
is alive and fairly healthy.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.8 HR 90 BP 95/63 RR 25 O2 95%RA
GENERAL: Chronically ill appearing woman in NAD, AOx3 and
appropriate but mildly drowsy
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with no JVD
CARDIAC: large palpable precordial heave RRR, normal S1, S2. No
m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm extremities with good cap refill. No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

PHYSICAL EXAM ON DISCHARGE:
VS: T97.4, HR:95, BP99/50, RR18, O2sat:97%RA
General: less drowsiness
Extremities: PICC in place
Exam otherwise unchanged from admission


Pertinent Results:
ADMISSION LABS:
WBC-8.9 RBC-4.82 Hgb-14.3 Hct-42.6 MCV-88 MCH-29.7 MCHC-33.6
RDW-13.1 Plt Ct-275
Neuts-74.3* Lymphs-21.1 Monos-3.1 Eos-0.7 Baso-0.7
Glucose-120* UreaN-27* Creat-0.9 Na-140 K-3.4 Cl-98 HCO3-31
AnGap-14
proBNP-4779*
cTropnT-<0.01
.
STUDIES:
.
CXR ([**2112-2-23**]): PA and lateral views of the chest are compared to
previous exam from [**2111-8-10**]. Again seen is cardiomegaly
which is essentially stable from prior. The lungs remain clear.
There is a small left pleural effusion. Pacemaker wires are in
stable position. There are surgical clips in the upper abdomen,
potentially from prior cholecystectomy.
IMPRESSION: Small left pleural effusion. Stable cardiomegaly.
.
RIGHT HEART CATH ([**2112-2-24**]):
1.  Resting hemodynamics revealed severely elevated filling
pressures
with a mean PCPW of 39mmHg and an RVEDP of 25mmHg.  There was
severe
pulmonary hypertension with a PA pressure of 71/41mmHg.  Cardiac
output
was diminished at 2.4L/min with an index of 1.3L/min/m2.
2.  Following milrinone bolus and infusion of 0.5mcg/kg/min,
PCWP
decreased to mean of 30mmHg.  PA pressure fell to 60/42mmHg, and
cardiac
output increased to 3.4L/min with an index of 1.9L/min/m2.

FINAL DIAGNOSIS:
1. Severe right- and left-sided heart failure with elevated
filling
pressures at rest.
2. Positive response to milrinone infusion with decrease in PA
pressure,
PCWP, and increase in cardiac output.
.
ECHO ([**2112-2-24**]):
Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is profoundly depressed (LVEF= 5 %). The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
mitral valve leaflets are structurally normal. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. AT LEAST
moderate [2+] tricuspid regurgitation is seen. [Due to acoustic
shadowing from the ICD coil, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.

Compared to the prior study of [**2111-4-20**], the left
ventricular ejection fraction is even further reduced, and now
severe right ventricular contractile dysfunction is present,
with markedly increased tricuspid regurgitation and at least
moderate pulmonary hypertension.
.
LENIs ([**2112-2-24**]): Normal appearance of the deep venous structures
of the right and left lower extremities. No evidence of deep
venous thrombosis.
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2112-2-25**] 7:30
AM
FINDINGS: As compared to the previous radiograph, the patient
has received a right internal jugular vein device, in addition
to the left pacemaker.
The size of the cardiac silhouette is still substantially
enlarged and the
presence of a small pleural effusion on the left cannot be
excluded.
Otherwise, there are signs of minimal fluid overload but no
overt pulmonary edema with no evidence of pneumonia. Unchanged
retrocardiac atelectasis.
.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2112-2-25**] 2:00 PM
Radiology Report -77 BY DIFFERENT PHYSICIAN [**Name9 (PRE) 2221**] Date of
[**2112-2-25**] 2:00 PM
The right PICC line tip is at the level of cavoatrial junction.
Right
internal jugular line tip is at the level of superior SVC. The
rest of the
findings are unchanged.
.
Cardiovascular Report ECG Study Date of [**2112-2-26**]  10:29:02 AM
Sinus rhythm with ventricular premature depolarizations.
Compared to the
previous tracing heart rate is reduced. Otherwise, no
significant change.
TRACING #2
.
Cardiovascular Report ECG Study Date of [**2112-2-26**]  9:53:36 AM
Sinus tachycardia. Left atrial abnormality. Non-specific QRS
widening. Left axis deviation. Left anterior fascicular block.
Diffuse non-diagnostic repolarization abnormalities. Compared to
the previous tracing of [**2112-2-24**] heart rate is increased.
Otherwise, no diagnostic change.
TRACING #1
.
Lab Results on Discharge:

[**2112-2-29**] 07:38AM BLOOD WBC-6.3 RBC-3.98* Hgb-11.8* Hct-34.9*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.2 Plt Ct-213
[**2112-2-24**] 05:50AM BLOOD Neuts-72.7* Lymphs-21.5 Monos-3.8 Eos-1.3
Baso-0.5
[**2112-3-1**] 09:00AM BLOOD PT-15.1* PTT-28.4 INR(PT)-1.4*
[**2112-3-1**] 09:00AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-136
K-3.5 Cl-102 HCO3-28 AnGap-10
[**2112-2-26**] 04:47AM BLOOD ALT-59* AST-29 AlkPhos-85 TotBili-0.4
[**2112-2-24**] 11:00AM BLOOD CK-MB-1 cTropnT-<0.01
[**2112-2-29**] 07:38AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.2
[**2112-2-26**] 12:30AM BLOOD Type-ART pO2-91 pCO2-38 pH-7.49*
calTCO2-30 Base XS-5 Intubat-NOT INTUBA
[**2112-2-26**] 12:30AM BLOOD Glucose-105 Lactate-1.7 Na-137 K-3.5
Cl-100
[**2112-2-25**] 05:19AM BLOOD Hgb-12.4 calcHCT-37 O2 Sat-64
[**2112-2-26**] 12:30AM BLOOD freeCa-1.20

Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 56 year old
woman with a history of severe dilated cardiomyopathy with an EF
of 5% (?viral vs. post-partum) s/p ICD placement who was
admitted on [**2112-2-23**] for severe SOB and PND, secondary to
worsening chronic systolic CHF. She was started on milrinone
drip and had improvement in symptoms and functional capacity
in-house. She was discharged home on milrinone drip with
follow-up with transplant cardiology at [**Hospital 3278**] Medical Center.
.
ACUTE CARE:
1. Chronic Systolic CHF: Patient presented with severe
dypspnea/orthopnea. This was especially bad at night when she
would have paroxysms of symptoms. Her EF was found to be 5%, BNP
elevated to 4000 from baseline of 1000, and left and right sided
pressures were markedly elevated (40s and 70s systolic
respectively) on right cath performed on admission. Patient was
subsequently admitted to CCU for initiation of milrinone. She
improved significantly on milrinone 0.5/hr infusion: CI rose
from 1 to 1.9, CO improved and trans-pulmonary gradient
decreased, which dramatically improved her pulmonary
hypertension. She was transiently hypotensive on milrinone [**2-11**]
milrinone's vasodilatory effects, which subsequently resolved
with MAPs consistently >55 afterward. Given her profoundly
reduced LV function, she was also started on Coumadin. Home
torsemide was restarted once pt was normotensive. Beta blocker
was initiated per patient's cardiologist.  PICC was placed for
home milrinone infusion. She was transferred back to the floor,
where PT eval on milrinone showed asymptomatic during ADL's and
even climbing stairs. She was discharged home on the milrinone
drip. Patient will ultimately require heart transplant at [**Hospital1 3278**]
after optimization of hemodynamics with milrinone.
.
# ARRYTHMIA: Patient went into multifocal ATach on HD#4 likely
[**2-11**] discontinuation of her beta blocker after initiation of
milrinone. This resolved and she returned to NSR after
metoprolol 5mg IV. Per patient request and with her
cardiologist's permission, she was restarted on low-dose
metoprolol without recurrence of MAT.
.
# Left wrist Superficial Thrombophlebitis: Patient developed
superficial thrombophelbitis of left wrist since peripheral line
removal in the ICU. There was a superficial 3x3cm area of
erythema, warmth, and tenderness to palpation with a palpable
cord on the lateral aspect of patient's left wrist. This
initally improved with warm packs and elevation alone, but then
developed increasing erythema, tenderness, and induration. She
was started on a 7-day course of keflex to complete at home but
noted some improvement after 2 days on antibitics in the
hospital.
.
CHRONIC CARE
1. H/O LYME DISEASE, FUNGAL INFECTIONS: Per patient report, she
has history of chronic Lyme disease for which she is followed by
integrative medicine specialist at an OSH. She also reports h/o
fungal infections (no further details available). Per ID
consult, no further workup needed at this time as these issues
are unlikely related to her chronic heart failure.
.
2. ABNORMAL LFTs: Most likely secondary to congestive
hepatopathy. Iron studies and hepatitis viral studies WNL. They
were downtrending to normal range and monitoring was stopped
when they approached normal.
.
3. DEPRESSION/ANXIETY: Patient endorsed depression and SI
without a plan in the ED. She later denied suicidality. She
underwent psych eval in CCU where she was found to be mildly
delirious and it was recommended that home benzos be limited.
They also feel that she would benefit from talk therapy and
possibly antidepressant therapy as an outpatient. Also followed
by social work. Her mood and affect improved on HD#2, although
she did remain significantly anxious requiring frequent
reassurance and low-dose klonopin throughout.
.
4. ASTHMA: Patient has a remote history of asthma and is on prn
ipratropium at home. This was continued during hospitalization
with no issues.
.
TRANSITIONS IN CARE:
1. Medication Changes:
   1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
   2. START cephalexin 500mg by mouth every 6 hours for six days
   3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
   4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the [**Hospital3 **]. This medication is
important in lowering the risk of stroke.
   5. START a daily multivitamin
   6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
   7. START metoprolol succinate 50mg by mouth once daily
   8. STOP taking metoprolol tartrate
   9. STOP taking losartan as your blood pressure is not
tolerating this medication
   10. CHANGE torsemide dosing to 40mg by mouth once daily.
   11. START fexofenadine 60mg by mouth twice daily.
   12. STOP nattokinase
   13. START potassium chloride 20meq by mouth daily
2. FOLLOW-UP:
You will be contact[**Name (NI) **] by [**Name8 (MD) **] NP that works with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Hospital 3278**] Medical Center for an initial appointment in
evaluation for heart transplant. If you do not hear from them
within a week, they can be reached at: [**Telephone/Fax (1) 72785**]

Please keep the following other appointments:

Department: CARDIAC SERVICES
When: MONDAY [**2112-3-7**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2112-3-14**] at 12:00 PM
With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE Best Parking: None

Department: CARDIAC SERVICES
When: MONDAY [**2112-6-13**] at 11:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks of
discharge.

3. OUTSTANDING CLINICAL ISSUES:
-maintenance of coumadin therapy
-evaluation for heart transplant
-follow-up TTE's
-titration of milrinone with cardiologist

Medications on Admission:
Active Medication list as of [**2112-2-23**]:

Medications - Prescription
CLONAZEPAM - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 1 mg Tablet - 1/2-1 Tablet(s) by mouth three times a
day as needed
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol Inhaler - 1-2 puffs inhaled twice a day for wheezing
LOSARTAN [COZAAR] - 25 mg Tablet - one Tablet(s) by mouth twice
a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth two
times a day
NATTOKINASE - (Prescribed by Other Provider) - - one capsule
twice a day
NYSTATIN - 100,000 unit/gram Powder - apply to inflammed area
twice a day
TERCONAZOLE [TERAZOL 7] - 0.4 % Cream - insert in vagina once a
day
TORSEMIDE - 20 mg Tablet - 1.5 Tablet(s) by mouth every morning,
0.5 tablets by mouth every evening

Medications - OTC
ASPIRIN - (Prescribed by Other Provider; OTC) (Not Taking as
Prescribed: forgets) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day (not taking because she forgets)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider; OTC;
Dose adjustment - no new Rx) - 300 mg Capsule - 1 Capsule(s) by
mouth twice a day


Discharge Medications:
1. milrinone in D5W 40 mg/200 mL Piggyback Sig: 0.5 mcg/kg/min
Intravenous continuous: OK to substitute 400mcg/mL strength
formulation.
[**2-29**] weight:74.8kg.
Disp:*30 day supply* Refills:*5*
2. clonazepam 1 mg Tablet Sig: 0.5-1 Tablet PO three times a day
as needed for anxiety: do not drive or operate machinery while
taking this medication.
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.

5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*28 Capsule(s)* Refills:*0*
7. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day.
8. terconazole 0.4 % Cream Sig: One (1) Appl Vaginal DAILY
(Daily) as needed for vaginal itching for 7 days.
9. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Vitamin D-3 2,000 unit Capsule Sig: One (1) Capsule PO once
a day.
11. coenzyme Q10 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day) as needed for nasal congestion.
Disp:*1 bottle* Refills:*2*
13. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
QID (4 times a day) as needed for dryness.
Disp:*1 bottle* Refills:*5*
14. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED) for 3 days: apply to affected area on lip every two
hours while awake for four days.
Disp:*1 unit* Refills:*0*
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
16. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
18. Outpatient Lab Work
Chem-10, PT/INR on [**2112-3-2**]


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary: Chronic Systolic Heart Failure

Secondary: Chronic pulmonary hypertension

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

Discharge Instructions:
Dear Mrs. [**Known lastname 111334**],

It was a pleasure taking part in your care. You were admitted
for shortness of breath. You underwent cardiac catheterization
which showed worsening heart failure. We started some new
medications and adjusted others and your symptoms improved. You
also developed skin infection in your forearm for which we
started antibiotics. You are now discharged home to await
evaluation for heart transplant.
.
Please make the following changes to your medications:
.
1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
2. START cephalexin 500mg by mouth every 6 hours for six days
3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the [**Hospital3 **]. This medication is
important in lowering the risk of stroke.
5. START a daily multivitamin
6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
7. START metoprolol succinate 50mg by mouth once daily
8. STOP taking metoprolol tartrate
9. STOP taking losartan as your blood pressure is not tolerating
this medication
10. CHANGE torsemide dosing to 40mg by mouth once daily.
11. START fexofenadine 60mg by mouth twice daily.
12. STOP nattokinase
13. START potassium chloride 20meq by mouth daily
.
Please take all other medications as prescribed
.
Please keep all follow-up appointments.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
You will be contact[**Name (NI) **] by [**Name8 (MD) **] NP that works with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at [**Hospital 3278**] Medical Center for an initial appointment in
evaluation for heart transplant. If you do not hear from them
within a week, they can be reached at: [**Telephone/Fax (1) 72785**]

Please keep the following other appointments:

Department: CARDIAC SERVICES
When: MONDAY [**2112-3-7**] at 10:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2112-3-14**] at 12:00 PM
With:  ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE     Best Parking: None

Department: CARDIAC SERVICES
When: MONDAY [**2112-6-13**] at 11:00 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please make an appointment to see your PCP [**Name Initial (PRE) 176**] 2 weeks of
discharge.
{'Acute on chronic systolic heart failure,Cellulitis and abscess of upper arm and forearm,Other primary cardiomyopathies,Drug-induced delirium,Other vascular complications of medical care, not elsewhere classified,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Candidiasis of vulva and vagina,Automatic implantable cardiac defibrillator in situ,Other iatrogenic hypotension,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: progressive dyspnea

PRESENT ILLNESS: Mrs. [**Known lastname 111334**] is a 56 year old woman with a history of severe
dilated cardiomyopathy with an EF of [**10-24**]% (?viral vs
post-partum) s/p ICD placement who was admitted on [**2112-2-23**] for
severe shortness of breath and PND, presumably due to worsening
congestive heart failure. Given the lack of edema or hypoxia,
the patient was continued on her home regimen fo torsemide 30mg
PO QAM and 10mg PO QPM. Notable findings during her stay
included a BNP >4000 (baseline of 1000), trigger for severe
dyspnea/orthopnea, and an echo that showed profoundly worsened
EF now down to 5% from 10-15%, with severe dilation of the LV.
At the behest of her cardiologist, Dr. [**First Name (STitle) 437**], she underwent a
right heart cath with plans for a trial of milrinone therapy.
RHC revealed markedly elevated left and right heart filling
pressures that significantly improved with milrinone infusion.
If this milrinone trial fails, she would likely be transferred
to [**Hospital1 3278**] for a heart transplant evaluation.
.
On arrival to the CCU, the patient subjectively felt much better
after milrinone infusion. She had by that point made nearly
700cc of urine.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- Idiopathic vs post partum cardiomyopathy atleast since [**2092**],
EF of [**10-24**]%
- 64 year old female with post-partum dilated cardiomyopathy s/p

MEDICATION ON ADMISSION: Active Medication list as of [**2112-2-23**]:

ALLERGIES: Morphine Sulfate / Pronestyl / Quinidine-Quinine Analogues /
Mexiletine / Captopril / Sulfa (Sulfonamide Antibiotics) / Latex
/ Nitrofurantoin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T 97.8 HR 90 BP 95/63 RR 25 O2 95%RA
GENERAL: Chronically ill appearing woman in NAD, AOx3 and
appropriate but mildly drowsy
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father died suddenly at age 74. She reports he may have had a
heart attack and had diabetes near the end of his life. Mother
is alive and fairly healthy.

SOCIAL HISTORY: [**Known firstname **] is married, lives with her husband and has two daughters.
She smoked cigarettes in her 20s and has not smoked tobacco
since. Occasional wine. 

### Response:
{'Acute on chronic systolic heart failure,Cellulitis and abscess of upper arm and forearm,Other primary cardiomyopathies,Drug-induced delirium,Other vascular complications of medical care, not elsewhere classified,Other chronic pulmonary heart diseases,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Candidiasis of vulva and vagina,Automatic implantable cardiac defibrillator in situ,Other iatrogenic hypotension,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
