CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: This is an 80 yo M with history of HTN, DM, anemia, who presents
with dyspnea. He was recently hospitalized from [**Date range (1) 55797**] for
pre-syncope in the setting of a junctional bradycardia.  He was
discharged to a [**Hospital 599**] Nursing Home in [**Location (un) 55**], where he
was experiencing worsening DOE in the last 2-3 days.  He also
complains of band-like chest discomfort while working with PT.
He denies nausea or vomiting with these episodes.  He also
denies lightheadedness/dizziness with these episodes as well.
.
During the patient's last admission, he was managed for
bradycardia likely due to hyperkalemia. Given his history of
claudication, his ASA was stopped and he was started on
clopidogrel. He was medically managed for presumed CAD despite a
pMIBI which did not show evidence of ischemia.  He was
discharged home on a clopidogrel, statin, and ACE-I.  He was not
started on a b-blocker due to his bradycardia at admission.
Also, the patient had cardiac enzymes on admission with a
trop<0.01 and CK 48.  His ECG was negative for ST segment
changes during that admission.
.
In the ED, his EKG showed new ST depressions in V5-V6.  CXR
showed new b/t pleural effusions.  His Hct was noted to be 24.6,
down from his baseline of 30.  He had an ABG on room air that
showed 7.51/26/59.  He was placed on a non-rebreather mask and
was unable to be weaned (86% RA).  He was placed on a heparin
gtt, given 1 unit pRBCS (guaiac negative), metoprolol 12.5, ASA
325 mg, and lasix 20 IV (put out approx 1000 cc).
.
On review of systems, he 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. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and dyspnea
on exertion (as described above), but he denies paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope, or
presyncope.
.
Patient does admit to exertional leg pain which he feels has
gotten worse.  He endorses occasional ankle edema.

MEDICAL HISTORY: Diabetes - A1c 7.3 in [**2141-9-2**].  alb/Cr ratio 800 in [**2141-10-2**].
Hypertension
PVD - sx of claudication, seen on MRA
Iron-deficiency anemia - Hct around 30, no colonscopy
spinal stenosis

MEDICATION ON ADMISSION: Amlodipine 10 mg daily
Simvastatin 20 mg daily
Omeprazole 20mg daily
Hydrochlorothiazide 12.5 daily
Lisinopril 20mg daily
Plavix 75 mg daily
Terazosin 4 mg QHS
Lantus 14 u QHS with humalog SSI
Vitamin D3 400 IU daily
Calcium 500 mg daily
Iron 65mg by mouth daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: VS - T 98.1, BP 131/60, HR 88, RR 22, 96% on NRB
Gen: thin elderly male in mild respiratory distress. Oriented
x3. Mood, affect appropriate. Tangential historian.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with 12 cm JVD. right carotid bruits.
CV: RR, normal S1. [**2-7**] holosystolic murmur loudest at apex. No
r/g.  No S3 or S4.
Chest: Resp were mild labored with some accessory muscle use.
Bibasilar crackles present [**Date range (1) 61126**] posterior lung fields.  No
wheezes or rhonchi.
Abd: mild voluntary guarding on exam; nontender.  nondistended.
No HSM.
Ext: No cyanosis or clubbing. 1+ edema BLE to knees.
Skin: Dry flaky skin on shins and feet.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT
absent
Left: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT absent

FAMILY HISTORY: Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

SOCIAL HISTORY: Social history is significant for quitting tobacco over 35 years
ago.  There is no current alcohol abuse.  Worked in a cemetery;
never married; never had kids.
Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Atrial flutter,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Delirium due to conditions classified elsewhere,Hydronephrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with intermittent claudication,Iron deficiency anemia, unspecified,Diarrhea,Other and unspecified complications of medical care, not elsewhere classified,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Other diseases of trachea and bronchus
Subendo infarct, initial,Mitral valve disorder,Crnry athrscl natve vssl,CHF NOS,Iatrogenic pneumothorax,Surg compl-heart,Atrial flutter,Meth sus pneum d/t Staph,Bacteremia,Delirium d/t other cond,Hydronephrosis,DMII wo cmp nt st uncntr,Hypertension NOS,Ath ext ntv at w claudct,Iron defic anemia NOS,Diarrhea,Complic med care NEC/NOS,Adv eff cardiotonics,Trachea & bronch dis NEC
Admission Date:  [**2141-11-20**]              Discharge Date:   [**2141-12-12**]

Date of Birth:  [**2060-12-20**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Hydrochlorothiazide

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
cardiac catheterization
[**11-24**] CABG x4 (LIMA>LAD, SVG>RAMUS SVG>OM SVG>PDA), MV repair


History of Present Illness:
This is an 80 yo M with history of HTN, DM, anemia, who presents
with dyspnea. He was recently hospitalized from [**Date range (1) 55797**] for
pre-syncope in the setting of a junctional bradycardia.  He was
discharged to a [**Hospital 599**] Nursing Home in [**Location (un) 55**], where he
was experiencing worsening DOE in the last 2-3 days.  He also
complains of band-like chest discomfort while working with PT.
He denies nausea or vomiting with these episodes.  He also
denies lightheadedness/dizziness with these episodes as well.
.
During the patient's last admission, he was managed for
bradycardia likely due to hyperkalemia. Given his history of
claudication, his ASA was stopped and he was started on
clopidogrel. He was medically managed for presumed CAD despite a
pMIBI which did not show evidence of ischemia.  He was
discharged home on a clopidogrel, statin, and ACE-I.  He was not
started on a b-blocker due to his bradycardia at admission.
Also, the patient had cardiac enzymes on admission with a
trop<0.01 and CK 48.  His ECG was negative for ST segment
changes during that admission.
.
In the ED, his EKG showed new ST depressions in V5-V6.  CXR
showed new b/t pleural effusions.  His Hct was noted to be 24.6,
down from his baseline of 30.  He had an ABG on room air that
showed 7.51/26/59.  He was placed on a non-rebreather mask and
was unable to be weaned (86% RA).  He was placed on a heparin
gtt, given 1 unit pRBCS (guaiac negative), metoprolol 12.5, ASA
325 mg, and lasix 20 IV (put out approx 1000 cc).
.
On review of systems, he 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. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and dyspnea
on exertion (as described above), but he denies paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope, or
presyncope.
.
Patient does admit to exertional leg pain which he feels has
gotten worse.  He endorses occasional ankle edema.

Past Medical History:
Diabetes - A1c 7.3 in [**2141-9-2**].  alb/Cr ratio 800 in [**2141-10-2**].
Hypertension
PVD - sx of claudication, seen on MRA
Iron-deficiency anemia - Hct around 30, no colonscopy
spinal stenosis

Social History:
Social history is significant for quitting tobacco over 35 years
ago.  There is no current alcohol abuse.  Worked in a cemetery;
never married; never had kids.

Family History:
Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

Physical Exam:
VS - T 98.1, BP 131/60, HR 88, RR 22, 96% on NRB
Gen: thin elderly male in mild respiratory distress. Oriented
x3. Mood, affect appropriate. Tangential historian.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with 12 cm JVD. right carotid bruits.
CV: RR, normal S1. [**2-7**] holosystolic murmur loudest at apex. No
r/g.  No S3 or S4.
Chest: Resp were mild labored with some accessory muscle use.
Bibasilar crackles present [**Date range (1) 61126**] posterior lung fields.  No
wheezes or rhonchi.
Abd: mild voluntary guarding on exam; nontender.  nondistended.
No HSM.
Ext: No cyanosis or clubbing. 1+ edema BLE to knees.
Skin: Dry flaky skin on shins and feet.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT
absent
Left: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT absent


Pertinent Results:
[**2141-12-12**] 06:30AM BLOOD WBC-17.4* RBC-2.93* Hgb-9.2* Hct-28.1*
MCV-96 MCH-31.2 MCHC-32.6 RDW-15.6* Plt Ct-732*
[**2141-12-11**] 06:50AM BLOOD WBC-18.1* RBC-3.01* Hgb-9.4* Hct-29.1*
MCV-97 MCH-31.2 MCHC-32.3 RDW-15.2 Plt Ct-714*
[**2141-12-12**] 06:30AM BLOOD Plt Ct-732*
[**2141-12-11**] 06:50AM BLOOD PT-16.7* INR(PT)-1.5*
[**2141-12-10**] 06:07AM BLOOD PT-17.6* PTT-37.9* INR(PT)-1.6*
[**2141-12-9**] 05:36AM BLOOD PT-18.6* INR(PT)-1.7*
[**2141-12-12**] 06:30AM BLOOD Glucose-46* UreaN-44* Creat-1.6* Na-149*
K-3.5 Cl-119* HCO3-21* AnGap-13
[**2141-12-11**] 06:50AM BLOOD Glucose-64* UreaN-45* Creat-1.7* Na-147*
K-3.7 Cl-119* HCO3-18* AnGap-14
[**2141-12-10**] 06:07AM BLOOD Glucose-248* UreaN-50* Creat-2.0* Na-151*
K-3.9 Cl-123* HCO3-20* AnGap-12
[**2141-11-20**] 07:40PM BLOOD Glucose-135* UreaN-38* Creat-1.2 Na-136
K-4.6 Cl-102 HCO3-20* AnGap-19

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 103627**], [**Known firstname 900**]       [**Hospital1 18**] [**Numeric Identifier 103628**] (Complete)
Done [**2141-11-24**] at 11:00:54 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**]  Status: Inpatient DOB: [**2060-12-20**]
Age (years): 80 M  Hgt (in):
BP (mm Hg): /  Wgt (lb):
HR (bpm):  BSA (m2):
Indication: Aortic valve disease. Congestive heart failure. Left
ventricular function. Mitral valve disease. Myocardial
infarction. Valvular heart disease.
ICD-9 Codes: 428.0, 440.0, V43.3, 396.9
Test Information
Date/Time: [**2141-11-24**] at 11:00    Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW02-: Machine:
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  0.9 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.9 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  *5.9 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  40% to 45%  >= 55%

Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.

LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary
veins identified and enter the left atrium.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.

LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Mildly dilated LV cavity. Mildly
depressed LVEF.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.

AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
mitral annular calcification. Moderate thickening of mitral
valve chordae. Moderate to severe (3+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.

REGIONAL LEFT VENTRICULAR WALL MOTION:





     N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. The left ventricular cavity is mildly dilated.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40-45 %). Right ventricular chamber size and free wall
motion are normal. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is moderate
thickening of the mitral valve chordae. Moderate to severe (3+)
mitral regurgitation is seen.
IABP in good position.

POST CPB:
Improved LV systolic function EF =55%. With back groung epi
infusion.
Annuloplasty ring in mitral position. Mechanically stable and
well seated. Good leaflet excursion , with no MR.
[**Name14 (STitle) 8751**] by PHT = 1.7 cm2/Mean Gradient = 7. 0 mm HG. (Cardiac Output
= 8.0 L/min)
No other change.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-11-28**] 13:30

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname 103627**], [**Known firstname 900**]       [**Hospital1 18**] [**Numeric Identifier 103628**] (Complete)
Done [**2141-11-28**] at 11:27:29 AM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]

[**Last Name (LF) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2060-12-20**]
Age (years): 80 M  Hgt (in): 70
BP (mm Hg): 125/43  Wgt (lb): 143
HR (bpm): 78  BSA (m2): 1.81 m2
Indication: Atrial flutter.
ICD-9 Codes: 427.32
Test Information
Date/Time: [**2141-11-28**] at 11:27    Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2007W0-0:0 Machine: Vivid i-4
    Sedation: Patient was monitored by a nurse throughout the
procedure
Echocardiographic Measurements
Results  Measurements  Normal Range

Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA ejection velocity.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.

AORTA: Complex (mobile) atheroma in the aortic arch. Complex
(>4mm) atheroma in the descending thoracic aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Trivial MR.

TRICUSPID VALVE: Mild [1+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was sedated for the TEE. Medications
and dosages are listed above (see Test Information section). No
TEE related complications.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is grossly preserved (not fully visualized). There are
complex (mobile) atheroma in the aortic arch. There are complex
(>4mm) atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear mildly thickened. The aortic valve
leaflets are mildly thickened. A mitral valve annuloplasty ring
is present. Trivial mitral regurgitation is seen.
Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-11-28**] 17:40

OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) **]
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] V on WED [**2141-11-29**]
5:40 PM


Name:  [**Known lastname 103627**], [**Known firstname 900**]
Unit No:  [**Numeric Identifier **]
Service:
Date:  [**2141-11-24**]
Date of Birth:  [**2060-12-20**]
Sex:  M
Surgeon:  [**Name6 (MD) 59497**] [**Name8 (MD) **], [**MD Number(1) 79029**]

OPERATION:  Coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and
saphenous vein grafts to the ramus, obtuse marginal and
posterior descending arteries and mitral valve repair with a
size 28 [**Doctor Last Name **] physio-ring.

ASSISTANT:  [**Name6 (MD) 59498**] [**Name8 (MD) 59499**], MD

PREOPERATIVE DIAGNOSIS:  This 80-year-old patient presented
with shortness of breath and lightheadedness and was found to
be in congestive heart failure.  He  was investigated and was
found to have severe triple-vessel disease with 80% left main
stem lesion, with severe mitral regurgitation and pulmonary
edema. He was electively intubated preoperatively and had a
balloon pump placed after angiogram. He was taken to the
operating room for coronary artery bypass grafting and mitral
valve repair or replacement. An intraoperative
transesophageal echocardiogram confirmed severe mitral
regurgitation with ejection fraction of about 45%.

POSTOPERATIVE DIAGNOSIS:  This 80-year-old patient presented
with shortness of breath and lightheadedness and was found to
be in congestive heart failure.  He  was investigated and was
found to have severe triple-vessel disease with 80% left main
stem lesion, with severe mitral regurgitation and pulmonary
edema. He was electively intubated preoperatively and had a
balloon pump placed after angiogram. He was taken to the
operating room for coronary artery bypass grafting and mitral
valve repair or replacement. An intraoperative
transesophageal echocardiogram confirmed severe mitral
regurgitation with ejection fraction of about 45%.

INCISION:  Routine median sternotomy.

FINDINGS:  The left internal mammary artery was of excellent
quality. The long saphenous vein from the leg was of moderate
quality, somewhat small in size. The ascending aorta was
normal size with some palpable disease in the innominate
artery. The left anterior descending artery was a good 2.5 mm
diseased vessel as was the ramus artery. The obtuse marginal
artery was a 1.5 mm vessel. The posterior descending artery
was a 2 mm vessel. The mitral pathology was mainly annular
dilatation and central regurgitation with no leaflet prolapse
as was seen in the transesophageal echocardiogram. This was
amenable for repair with complete ring. The left atrium was
moderately dilated with no clots.

PROCEDURE:  After informed consent, the patient was
transferred from the intensive care unit intubated and with a
balloon pump to the operating room. The patient remained
hemodynamically stable. He was prepped and draped in routine
fashion. Median sternotomy incision was made. Simultaneous
harvesting of the pedicle of the left internal mammary artery
and endoscopic harvesting of the long saphenous vein from the
leg were done. The mammary artery was of good quality. The
vein was small in some sections, otherwise usable. The best
pieces were used for the grafting. Next the pericardium was
opened. The patient was fully heparinized. Cardiopulmonary
bypass was instituted using ascending aortic arterial cannula
and a 3-stage venous cannula in the right atrium and  IVC,
antegrade as well as retrograde coronary sinus catheters were
inserted. The patient was cooled down to 32 dB Centigrade.
The aorta was crossclamped. Myocardial protection obtained by
infusion of antegrade as well as retrograde coronary sinus
infusion of cold multidose blood cardioplegia along with
topical iced saline.  After arresting the heart, bypass
grafting was commenced. First the ramus artery which was a
2.5 mm vessel was opened. A piece of reversed saphenous vein
graft was anastomosed to this using 7-0 Prolene sutures. Next
the posterior descending artery which was opened quite
proximally, a 2 mm vessel and another piece of vein was
anastomosed to this. Next the obtuse marginal artery was
exposed very proximally. Distally it was quite small. Very
proximally, it was about a 2 mm vessel and another piece of
vein was anastomosed to this. Next the mitral valve was
approached through a left atriotomy. A size 28 Physio
complete ring was chosen. This was inserted using 2-0
Ethibond interrupted sutures. The ring was tied down
satisfactorily with no residual mitral regurgitation. The
left atriotomy was closed in layers of Prolene. Next during
the process of rewarming, the left internal mammary artery
was anastomosed to the left anterior descending artery which
was a 2.5 mm good vessel. Using a single aortic crossclamp
technique, the 3 proximal ends of the vein graft were
anastomosed to the ascending aorta. The crossclamp was
removed. Heart started beating spontaneously in a slow
rhythm. Atrial and ventricular pacing wires were inserted.
Thorough de-airing of the heart was done through the aortic
root cannula and was confirmed by echo. After full rewarming
to 37 dB Centigrade, cardiopulmonary bypass was discontinued
uneventfully with no inotropic support. Good biventricular
function and excellent repair of the mitral valve with no
residual regurgitation was confirmed by echo. Routine
decannulation and reversal of heparin with protamine was
done. Good hemostasis was obtained. He had significant
bilateral large pleural effusions.  Both pleura were opened
wide and 2 pleural chest tubes along with 2 mediastinal chest
tubes were placed. Sternum was closed with 6 sternal wires.
The wound was closed in layers. The patient was transferred
back to the intensive care unit in stable condition with
minimal inotropic support, minimal chest tube drainage. The
swabs, needles, instrument counts were reported correct at
the end of the procedure.

                        [**Name6 (MD) 59497**] [**Name8 (MD) **], MD
[**MD Number(2) 69417**]

Dictated By:[**Name8 (MD) 79030**]
MEDQUIST36
D:  [**2141-11-24**] 12:40:41
T:  [**2141-11-24**] 20:40:02
Job#:  [**Job Number 103629**]

OPERATIVE REPORT

[**Last Name (LF) 1533**],[**First Name3 (LF) 1532**] P.
**NOT REVIEWED BY ATTENDING**


Name:  [**Known lastname 103627**], [**Known firstname 900**]
Unit No:  [**Numeric Identifier **]
Service:
Date:  [**2141-12-1**]
Date of Birth:  [**2060-12-20**]
Sex:  M
Surgeon:  [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 67965**]

PREOPERATIVE DIAGNOSIS:  Respiratory failure.

POSTOPERATIVE DIAGNOSIS:  Respiratory failure.

PROCEDURE:  An 8-0 Portex tracheostomy tube and flexible
bronchoscopy, 20 French Ponsky PEG tube placement.

ASSISTANT:  [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **], RES and [**Name6 (MD) **] [**Name8 (MD) 41455**], MD

ANESTHESIA:  General endotracheal.

IV FLUIDS:  500

ESTIMATED BLOOD LOSS:  Minimal.

INDICATIONS FOR PROCEDURE:  Mr. [**Known lastname **] is an 80-year-old
gentleman who underwent a cardiac procedure several days ago
and has had persistent ventilator dependence.

PROCEDURE IN DETAIL:  The patient was positioned supine and
had his neck extended and he was prepped and draped in the
usual sterile fashion.

We created a 4 cm incision 1 finger breadth above the sternal
notch and used electrocautery to divide the subcutaneous
tissue and platysma and then split the median raphe between
the strap muscles in a vertical direction. We then suture
ligated the [**Known lastname **] isthmus with 2-0 silk. We absolutely
identified the second tracheal ring and incised the space
between the second and third tracheal rings. We then used an
adenoid punch to resect a portion of the second and third
tracheal rings. We then used electrocautery to achieve
hemostasis of the mucosal surface.

We then withdrew the endotracheal tube past the tracheotomy
and then placed an 8-0 Portex tube into the lumen of the
trachea without undue resistance. We confirmed placement of
the chest rise and end tidal CO2. We then inspected for
hemostasis and were happy. We anchored the tube to the skin
using zero Prolene.

Next, we redraped the abdomen in sterile fashion. We
performed upper endoscopy to the first portion of the
duodenum and found no anatomic abnormalities or mucosal
abnormalities. We insufflated the stomach and then palpated
the left subcostal region and saw good indentation of the
gastric antrum. We saw good transillumination as well.

We placed an angiocatheter percutaneously into the gastric
antrum. Through this, we placed a wire which was grasped with
a snare through the gastroscope and then withdrawn retrograde
through the patient's mouth. We anchored this to the Ponsky
tube and pulled this so that the mushroom cap lay comfortably
on the antral mucosa. This was at 2 cm at the skin level.

We then inspected once more with the scope for any injury and
there was none. All sponge and needle counts were correct x2.
I  was present and scrubbed for the entire procedure. At the
completion, we did also do a bronchoscopy and aspirated some
mucopurulent secretions from the right lower lobe.

                        [**Name6 (MD) **] [**Name8 (MD) **], MD

CHEST (PORTABLE AP)  [**2141-12-11**] 7:48 AM

CHEST (PORTABLE AP)

Reason: ? effusion

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
INDICATION: Status post CABG. Assess for effusion.

COMPARISON: [**2141-12-7**].

UPRIGHT AP CHEST: The tracheostomy tube is 7.9 cm above the
carina. Sternal wires and valve replacement are unchanged. The
central venous catheter has been removed since [**12-7**]. No
pneumothorax is seen. Moderate pulmonary edema is worsened,
particularly on the right. Bilateral pleural effusions, left
greater than right, persists. No pneumothorax. A gastrostomy is
seen in the left upper quadrant.

IMPRESSION: Worsened congestive heart failure.


Brief Hospital Course:
80 yo M with HTN, DM, anemia, ataxia likely due to spinal
stenosis, and symptoms of peripheral arterial disease presenting
with dyspnea, chest pain, and ECG changes/cardiac enzyme
elevations consistent with NSTEMI.

EKG on admission consistent with lateral NSTEMI with V5-V6
depressions and troponin peak of 1.33, CK peak of 191. ACS
protocol was initiated with ASA, plavix, heparin gtt, high-dose
statin, metoprolol, and ACE-I. He was also transfused 2 units
pRBC to keep his Hct > 30. A TTE was significant for new onset
focal inferior hypokinesis and moderate to severe MR. The
patient was electively intubated for a cardiac catheterization
the following morning after discussion with the patient as he
was unable to lie flat to tolerate a cath secondary to shortness
of breath in spite of diuresis. The cath was significant for
severe 3 vessel disease and an IABP was placed. He was evaluated
by cardiac surgery and he was taken to the operating room on
[**11-24**] where he underwent a CABG x 4/MV Repair. He was
transferred to the ICU in critical but stable condition on
epinephrine, neosynephrine and propofol, and IABP. He received
perioperative Vancomycin because he was inpatient prior to his
surgery. His IABP was dc'd and his epinephrine was weaned to off
on POD #1. He had atrial fibrillation for which he was given
amiodarone, and he subsequently became asystolic. He was paced,
and returned to atrial fibrillation. He was started on heparin.
He was found to have right sided weakness and had a CT of the
head which was negative for acute infarct. He underwent TEE
which showed no thrombus, and he was cardioverted with return to
NSR. He remained ventilator dependent, sedation was held, and
tube feeds were started. A right thoracentesis was attempted for
large right effusion, no fluid was withdrawn, CXR showed large
pneumothorax and a right chest tube was placed. He was extubated
on [**11-30**] and reintubated approximately 1 hour later for
respiratory distress. He was seen by thoracic surgery and
underwent tracheostomy and PEG tube placement on [**12-1**]. He was
started on nafcillin and zosyn for GPC in blood and sputum.
Coumadin was started for afib. He was weaned to trach collar on
[**12-4**] and TF were advanced via peg. On [**12-5**] a CT of the chest
and abdomen was done for increased WBC and revealed a large left
lower lobe effusion which was drain via thoracentesis for 1100ml
of serous fluid. on [**12-6**] he was started empirically on Flagyl
for diarrhea pending results fo cdiff B toxin, cdiff a has been
negative. On [**12-6**], he passed his PMV evaluation but failed his
swallow evaluation. On [**12-7**] he was stable and transferred to
the floor for further management of his post-operative care. He
continued to improved neurologically and on POD #18 he was ready
for discharge to rehab.

Medications on Admission:
Amlodipine 10 mg daily
Simvastatin 20 mg daily
Omeprazole 20mg daily
Hydrochlorothiazide 12.5 daily
Lisinopril 20mg daily
Plavix 75 mg daily
Terazosin 4 mg QHS
Lantus 14 u QHS with humalog SSI
Vitamin D3 400 IU daily
Calcium 500 mg daily
Iron 65mg by mouth daily

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
4. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
8. Insulin Lispro 100 unit/mL Solution Sig: sliding scalew
Subcutaneous every six (6) hours.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check inr [**12-13**] and dose accordingly.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-3**]
Puffs Inhalation Q6H (every 6 hours) as needed.
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: through [**12-18**].
13. Nafcillin 2 gm IV Q6H Duration: 3 Weeks
completes [**12-31**]
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 3 days: through [**12-14**].
15. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
CAD, MR now s/p CABG/MV Repair
PMH:
DM, HTN, PVD, anemia, spinal stenosis


Discharge Condition:
Stable.


Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.

Followup Instructions:
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 2450**] after discharge from rehab
Already scheduled appointments:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-12-27**] 1:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2142-9-10**] 12:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-12-21**]
2:30


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2141-12-12**]
{'Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Atrial flutter,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Delirium due to conditions classified elsewhere,Hydronephrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with intermittent claudication,Iron deficiency anemia, unspecified,Diarrhea,Other and unspecified complications of medical care, not elsewhere classified,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Other diseases of trachea and bronchus'}


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: This is an 80 yo M with history of HTN, DM, anemia, who presents
with dyspnea. He was recently hospitalized from [**Date range (1) 55797**] for
pre-syncope in the setting of a junctional bradycardia.  He was
discharged to a [**Hospital 599**] Nursing Home in [**Location (un) 55**], where he
was experiencing worsening DOE in the last 2-3 days.  He also
complains of band-like chest discomfort while working with PT.
He denies nausea or vomiting with these episodes.  He also
denies lightheadedness/dizziness with these episodes as well.
.
During the patient's last admission, he was managed for
bradycardia likely due to hyperkalemia. Given his history of
claudication, his ASA was stopped and he was started on
clopidogrel. He was medically managed for presumed CAD despite a
pMIBI which did not show evidence of ischemia.  He was
discharged home on a clopidogrel, statin, and ACE-I.  He was not
started on a b-blocker due to his bradycardia at admission.
Also, the patient had cardiac enzymes on admission with a
trop<0.01 and CK 48.  His ECG was negative for ST segment
changes during that admission.
.
In the ED, his EKG showed new ST depressions in V5-V6.  CXR
showed new b/t pleural effusions.  His Hct was noted to be 24.6,
down from his baseline of 30.  He had an ABG on room air that
showed 7.51/26/59.  He was placed on a non-rebreather mask and
was unable to be weaned (86% RA).  He was placed on a heparin
gtt, given 1 unit pRBCS (guaiac negative), metoprolol 12.5, ASA
325 mg, and lasix 20 IV (put out approx 1000 cc).
.
On review of systems, he 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. He denies recent fevers, chills or rigors.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for chest pain and dyspnea
on exertion (as described above), but he denies paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope, or
presyncope.
.
Patient does admit to exertional leg pain which he feels has
gotten worse.  He endorses occasional ankle edema.

MEDICAL HISTORY: Diabetes - A1c 7.3 in [**2141-9-2**].  alb/Cr ratio 800 in [**2141-10-2**].
Hypertension
PVD - sx of claudication, seen on MRA
Iron-deficiency anemia - Hct around 30, no colonscopy
spinal stenosis

MEDICATION ON ADMISSION: Amlodipine 10 mg daily
Simvastatin 20 mg daily
Omeprazole 20mg daily
Hydrochlorothiazide 12.5 daily
Lisinopril 20mg daily
Plavix 75 mg daily
Terazosin 4 mg QHS
Lantus 14 u QHS with humalog SSI
Vitamin D3 400 IU daily
Calcium 500 mg daily
Iron 65mg by mouth daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: VS - T 98.1, BP 131/60, HR 88, RR 22, 96% on NRB
Gen: thin elderly male in mild respiratory distress. Oriented
x3. Mood, affect appropriate. Tangential historian.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: Supple with 12 cm JVD. right carotid bruits.
CV: RR, normal S1. [**2-7**] holosystolic murmur loudest at apex. No
r/g.  No S3 or S4.
Chest: Resp were mild labored with some accessory muscle use.
Bibasilar crackles present [**Date range (1) 61126**] posterior lung fields.  No
wheezes or rhonchi.
Abd: mild voluntary guarding on exam; nontender.  nondistended.
No HSM.
Ext: No cyanosis or clubbing. 1+ edema BLE to knees.
Skin: Dry flaky skin on shins and feet.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT
absent
Left: Carotid 2+ Femoral 2+ Popliteal absent DP absent PT absent

FAMILY HISTORY: Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

SOCIAL HISTORY: Social history is significant for quitting tobacco over 35 years
ago.  There is no current alcohol abuse.  Worked in a cemetery;
never married; never had kids. 

### Response:
{'Subendocardial infarction, initial episode of care,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic pneumothorax,Cardiac complications, not elsewhere classified,Atrial flutter,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Delirium due to conditions classified elsewhere,Hydronephrosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Atherosclerosis of native arteries of the extremities with intermittent claudication,Iron deficiency anemia, unspecified,Diarrhea,Other and unspecified complications of medical care, not elsewhere classified,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Other diseases of trachea and bronchus'}
