CHIEF COMPLAINT: xfer from [**Location (un) **], ? new afib

PRESENT ILLNESS: 78yo M, dizziness with PMH of IDDM, afib not on coumadin (GIB,
frequent falls), bradycardia s/p pacer, diastolic CHF with EF
55%, chronic microvascular infarcts who presented to an OSH
after falling at home. He reports to me that his legs felt weak
and then he lost consciousness. He denied lightheadedness, chesp
pain, palpitations, loss of bowel/bladder, though per OSH notes,
he reportedly had dizziness and one second of chest pain before
falling. He endorses orthopnea, chronic SOB, denies PND. Per
OSH, he was down for roughly one hour. In the OSH, he had a
negative head CT, EKGs showed anterolateral ST-TW changes, and
he had a CPK of over 1200 with MB 18.4 and TropI of 0.8. An ECHO
showed EF 40-45%. He was started on heparin at some point during
his stay. On [**3-25**], complained of L shoulder pain without N/V,
F/C, SOB, chest discomfort. PE showed large bruise on left
lateral chest wall. Heparin was discontinued. CT scan showed
chest hematoma and lymphnodes suspicious for malignancy. On
[**3-25**], his HCT was 31.7, down from 44 on admission. He was noted
to have an decrease in EF compared to previous ECHOs, so he was
transferred to [**Hospital1 18**] for possible cath. On the floor he denies
chest pain, lightheadedness, but endorses shortness of breath.
.
Has chest wall hematoma.

MEDICAL HISTORY: IDDM
afib, not on coumadin (GIB and frequent falls)
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)

MEDICATION ON ADMISSION: Home Meds:
NPH 10 units [**Hospital1 **]
lovastatin 20 qd
calcitriol 0.25 mg q MWF
Lasix 20mg qd
coreg 12.5 po bid
lisinopril 5mg qd
vit d.
asa 325
plavix 75
colace
senna
.
OSH Meds upon transfer:
mucomyst 600mg [**Hospital1 **]
aspirin 325
calcium carbonate 500 tid with meals
calcitriol 0.25 q M/W/F
carvedilol 12.5 [**Hospital1 **]
plavix 75 qday
colace
ferrous sulfate 325 tid
lasix 20 po qday
lisinopril 5 qday
multivitamins
simvastatin 40 vitamin D 400IU daily
NPH 10 [**Hospital1 **]
ssi novolog
nitropaste 2 inch q 4 hrs
tylenol
guaifenesin/dextromethorphan
morphine sulfate 1-2 mg IV q 4 hr prn pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.6; BP 135/89; HR 77; RR 18; 100% on 2L
gen: well appearing, nad, pleasant
heent: ncat, mmm, eomi, anicteric sclera
neck: supple, no elevated jvd
chest: poor air movement, bibasilar crackles 1/3 up lung fields,
no wheezes. Large left sided echymosis.
cv: heart irregularly irregular, nl s1/s2, no m/r/g
abd: s/nd/nabs, mild ttp diffusely, no rebound
extr: no c/c/e, 1+ distal pulses
neuro: oriented to person and place, not to time. left sided
facial droop, upper extremity strenth 3+/5 on right, [**3-15**] on
left, LE [**4-15**] left weaker than right. Sensation to light touch
intact throughout. Poor neuro exam d/t cooperation.

FAMILY HISTORY: There is no family history of premature coronary artery disease

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Diastolic heart failure, unspecified,Chronic kidney disease, Stage IV (severe),Encephalopathy, unspecified,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acidosis,Bacteremia,Subendocardial infarction, subsequent episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy,Abnormality of gait,Hemorrhage, unspecified,Other iatrogenic hypotension,Bell's palsy,Shock therapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anticoagulants causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nonspecific low blood pressure reading,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Other psoriasis,Retention of urine, unspecified,Personal history of tobacco use,Fitting and adjustment of cardiac pacemaker,Cataract extraction status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Atrial fibrillation,Crbl art ocl NOS w infrc,Diastolc hrt failure NOS,Chr kidney dis stage IV,Encephalopathy NOS,Acute kidney failure NOS,Food/vomit pneumonitis,Acidosis,Bacteremia,Subendo infarct, subseq,Hy kid NOS w cr kid I-IV,Encountr palliative care,Crnry athrscl natve vssl,Idio periph neurpthy NOS,Abnormality of gait,Hemorrhage NOS,Iatrogenc hypotnsion NEC,Bell's palsy,Abn react-shock therapy,Adv eff anticoagulants,Anemia in chr kidney dis,Low blood press reading,Long-term use of insulin,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Other psoriasis,Retention urine NOS,History of tobacco use,Ftng cardiac pacemaker,Cataract extract status,Hx TIA/stroke w/o resid
Admission Date:  [**2119-3-26**]              Discharge Date:   [**2119-4-7**]

Date of Birth:  [**2041-2-22**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 22990**]
Chief Complaint:
xfer from [**Location (un) **], ? new afib

Major Surgical or Invasive Procedure:
DC cardioversion
Dobbhoff feeding tube placement


History of Present Illness:
78yo M, dizziness with PMH of IDDM, afib not on coumadin (GIB,
frequent falls), bradycardia s/p pacer, diastolic CHF with EF
55%, chronic microvascular infarcts who presented to an OSH
after falling at home. He reports to me that his legs felt weak
and then he lost consciousness. He denied lightheadedness, chesp
pain, palpitations, loss of bowel/bladder, though per OSH notes,
he reportedly had dizziness and one second of chest pain before
falling. He endorses orthopnea, chronic SOB, denies PND. Per
OSH, he was down for roughly one hour. In the OSH, he had a
negative head CT, EKGs showed anterolateral ST-TW changes, and
he had a CPK of over 1200 with MB 18.4 and TropI of 0.8. An ECHO
showed EF 40-45%. He was started on heparin at some point during
his stay. On [**3-25**], complained of L shoulder pain without N/V,
F/C, SOB, chest discomfort. PE showed large bruise on left
lateral chest wall. Heparin was discontinued. CT scan showed
chest hematoma and lymphnodes suspicious for malignancy. On
[**3-25**], his HCT was 31.7, down from 44 on admission. He was noted
to have an decrease in EF compared to previous ECHOs, so he was
transferred to [**Hospital1 18**] for possible cath. On the floor he denies
chest pain, lightheadedness, but endorses shortness of breath.
.
Has chest wall hematoma.


Past Medical History:
IDDM
afib, not on coumadin (GIB and frequent falls)
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)

Social History:
Social history is significant for the absence of current tobacco

use. There is he drinks 1-2 drinks of ETOH per day. lives alone
in apt in [**Location (un) **].


Family History:
There is no family history of premature coronary artery disease

or sudden death.


Physical Exam:
VS: 98.6; BP 135/89; HR 77; RR 18; 100% on 2L
gen: well appearing, nad, pleasant
heent: ncat, mmm, eomi, anicteric sclera
neck: supple, no elevated jvd
chest: poor air movement, bibasilar crackles 1/3 up lung fields,
no wheezes. Large left sided echymosis.
cv: heart irregularly irregular, nl s1/s2, no m/r/g
abd: s/nd/nabs, mild ttp diffusely, no rebound
extr: no c/c/e, 1+ distal pulses
neuro: oriented to person and place, not to time. left sided
facial droop, upper extremity strenth 3+/5 on right, [**3-15**] on
left, LE [**4-15**] left weaker than right. Sensation to light touch
intact throughout. Poor neuro exam d/t cooperation.


Pertinent Results:
[**2119-3-26**] 11:50PM BLOOD WBC-8.9 RBC-3.16*# Hgb-10.2*# Hct-28.8*#
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.6 Plt Ct-157
[**2119-3-30**] 01:58PM BLOOD WBC-11.2* RBC-3.20* Hgb-10.6* Hct-29.7*
MCV-93 MCH-33.0* MCHC-35.6* RDW-14.0 Plt Ct-228
[**2119-3-31**] 07:45PM BLOOD WBC-7.8 RBC-2.70* Hgb-8.6* Hct-25.4*
MCV-94 MCH-32.0 MCHC-34.1 RDW-14.7 Plt Ct-187
[**2119-3-26**] 11:50PM BLOOD PT-14.3* PTT-29.9 INR(PT)-1.2*
[**2119-3-31**] 07:45PM BLOOD PT-27.2* PTT-37.2* INR(PT)-2.7*
[**2119-3-26**] 11:50PM BLOOD Glucose-101 UreaN-42* Creat-2.6* Na-139
K-4.0 Cl-107 HCO3-20* AnGap-16
[**2119-3-31**] 07:45PM BLOOD Glucose-130* UreaN-57* Creat-3.2* Na-136
K-4.1 Cl-106 HCO3-20* AnGap-14
[**2119-3-30**] 01:58PM BLOOD ALT-26 AST-23 LD(LDH)-250 AlkPhos-81
TotBili-2.0*
[**2119-3-26**] 11:50PM BLOOD CK(CPK)-403*
[**2119-3-26**] 11:50PM BLOOD CK-MB-6 cTropnT-0.15*
[**2119-3-27**] 07:25AM BLOOD CK(CPK)-364*
[**2119-3-27**] 07:25AM BLOOD CK-MB-7 cTropnT-0.21*
[**2119-3-29**] 01:00AM BLOOD CK(CPK)-156
[**2119-3-29**] 01:00AM BLOOD CK-MB-6 cTropnT-0.12*
[**2119-3-30**] 08:00AM BLOOD CK(CPK)-176*
[**2119-3-30**] 08:00AM BLOOD CK-MB-8 cTropnT-0.17*
[**2119-3-31**] 07:45PM BLOOD CK(CPK)-224*
[**2119-3-31**] 07:45PM BLOOD CK-MB-7 cTropnT-0.40*
[**2119-3-31**] 07:45PM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
[**2119-3-29**] 07:15AM BLOOD VitB12-1178* Folate-11.3
[**2119-3-29**] 02:01PM BLOOD %HbA1c-5.8
[**2119-3-29**] 07:15AM BLOOD Triglyc-83 HDL-32 CHOL/HD-2.6 LDLcalc-35
[**2119-3-29**] 07:15AM BLOOD TSH-0.90
[**2119-4-1**] 01:19AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.0 Leuks-TR
[**2119-4-1**] 01:19AM URINE RBC-21-50* WBC-[**3-15**] Bacteri-FEW Yeast-NONE
Epi-0-2
[**2119-4-4**] COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
       [**2119-4-4**] 05:30AM    9.8 3.06* 9.8* 28.6* 93 32.0 34.3
19.2* 200
RENAL & GLUCOSE    Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2119-4-4**] 05:30AM    132* 88* 3.9* 140 4.8 110* 16* 19

.
UCx negative [**2119-3-29**]
.
CT HEAD W/O CONTRAST  [**2119-3-27**] 5:37 PM
FINDINGS: Several axial slices are degraded by motion artifact,
some of which were subsequently repeated. A metallic density is
noted adjacent to the left orbit creating streak artifact
limiting evaluation in this region. There is no evidence of
acute hemorrhage or mass effect. There is no hydrocephalus. The
major intracranial cisterns are preserved.
There is near complete opacification of the right maxillary
sinus with a focus of high-attenuation material within, possibly
representing calcification or fungal chronic infection. This
region opacification appears to distort the superomedial
maxillary sinus wall with extension into the adjacent ethmoid
sinuses. A small amount of opacification is detected in the left
maxillary sinus. The right mastoid air cells are completely
opacified while the left are clear. There is complete
opacification of the right frontal sinus.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Opacification of multiple right-sided sinuses. Given the
unilateral aspect of this process, this may represent a
congenital process. Recommend correlation with clinical history
and outside hospital radiographs if available. A CT or MRI of
the paranasal sinuses with contrast may be obtained for further
evaluation if indicated.
.
Portable TTE (Complete) Done [**2119-3-27**] at 8:31:04 AM      FINAL

Findings
This study was compared to the prior study of [**2118-9-21**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%).
Transmitral Doppler and TVI c/w Grade III/IV (severe) LV
diastolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus. Focal calcifications in
aortic root. Moderately dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild to moderate
([**1-11**]+) MR. LV inflow pattern c/w restrictive filling
abnormality, with elevated LA pressure.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor parasternal
views. Suboptimal image quality - poor subcostal views.
Suboptimal image quality -poor suprasternal views. The rhythm
appears to be atrial fibrillation.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler and tissue velocity imaging are
consistent with Grade III/IV (severe) LV diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is moderately dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. Mild to moderate ([**1-11**]+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
TEE (Complete) Done [**2119-3-29**] at 11:56:11 AM      FINAL
Findings
LEFT ATRIUM: Dilated LA. No thrombus/mass in the body of the LA.
Mild spontaneous echo contrast in the LAA. Depressed LAA
emptying velocity (<0.2m/s) No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the body of the RA or RAA. No mass or thrombus in the RA or RAA.
Normal interatrial septum. No ASD by 2D or color Doppler.
AORTA: Complex (>4mm) atheroma in the aortic arch. Complex
(>4mm) atheroma in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to
moderate ([**1-11**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). The posterior pharynx was anesthetized
with 2% viscous lidocaine. 0.2 mg of IV glycopyrrolate was given
as an antisialogogue prior to TEE probe insertion. No TEE
related complications.
Conclusions
The left atrium is dilated. No thrombus/mass is seen in the body
of the left atrium. Mild spontaneous echo contrast is present in
the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No thrombus is seen in the left
atrial appendage. No spontaneous echo contrast is seen in the
body of the right atrium or right atrial appendage. No mass or
thrombus is seen in the right atrium or right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There
are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**1-11**]+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: No left atrial appendage thrombus. Dilated left
atrium and left atrial appendage with significant spontaneous
echo contrast and reduced ejection velocity of the left atrial
appendage. Mild to moderate mitral and mild tricuspid
regurgitation.
.
CHEST (PORTABLE AP)  [**2119-3-30**] 2:52 PM
CHEST AP: There is stable moderate cardiomegaly and pulmonary
vascular congestion. The degree of interstitial edema is not
significantly changed. No pleural effusion is definitely
identified. Single lead pacemaker or ICD device is in unchanged
position.
IMPRESSION: Unchanged mild pulmonary edema.
.
CT HEAD W/O CONTRAST  [**2119-3-30**] 10:40 AM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect or acute territorial infarction. There is no evidence of
hydrocephalus. The major intracranial cisterns are preserved.
Again there is almost complete opacification of the right
maxillary sinus with a focus of high attenuation material
within, likely consistent with a calcification or chronic fungal
colonization with extension into the adjacent ethmoidal air
cells. Unchanged opacity of the left maxillary sinus. Again the
right mastoid air cells are completely opacified and the left
remain clear. Unchanged opacity of the right frontal sinus.
Metallic density is again noted on the left orbit producing
significant streak artifact.
IMPRESSION:
No significant change in comparison with the prior study, there
is no evidence of intracranial acute hemorrhage.
Persistent opacity of multiple right-sided paranasal sinuses. A
dedicated CT of the paranasal sinuses is recommended, if
clinically warranted, MRI could be obtained if the metallic
material noted on the left orbit is MRI compatible.
.
CHEST (PORTABLE AP)  [**2119-3-30**] 3:18 AM
FRONTAL CHEST RADIOGRAPH: A single lead right-sided pacemaker is
seen in unchanged position. There is mild cardiomegaly.
Interstitial markings have mildly increased. There is no focal
consolidation, pneumothorax, or pleural effusion.
IMPRESSION: Subtle increase in interstitial markings indicating
mild
.
CT HEAD W/O CONTRAST  [**2119-3-31**] 5:51 PM
FINDINGS: There is no intra- or extra-axial hemorrhage, shift of
the normally midline structures, mass effect or hydrocephalus.
Periventricular and subcortical white matter hypodensity
reflects changes of chronic microvascular ischemia. Prominence
of the ventricles and sulci is consistent with age- related
atrophy. Metallic density is again noted adjacent to the left
orbit creating streak artifact, limiting evaluation of this
region. Basal cisterns are not effaced. As before, there is
almost complete opacification of the right maxillary sinus with
focal increased attenuation representing inspissated secretions
versus fungal colonization. This process extends into the
adjacent ethmoid air cells. There is unchanged opacity of the
left maxillary sinus and right mastoid air cells. The right
frontal sinus is nearly completely opacified. No fractures are
seen.
IMPRESSION: No significant change in comparison to the prior
study. No evidence of acute intracranial hemorrhage. As before,
dedicated CT of the paranasal sinuses is recommended given
persistent opacity at multiple right- sided nasal sinuses.
.
CHEST (PORTABLE AP)  [**2119-3-31**] 7:26 PM
COMPARISON: [**2119-3-30**].
As compared to the previous examination, there is no major
change. Moderate cardiomegaly with moderate signs of
overhydration. No pleural effusions, no masses.
.
ECG Study Date of [**2119-3-26**]  8:19:56 PM
Artifact is present. Atrial fibrillation with a controlled
ventricular
response. Ventricular ectopy. Diffuse non-specific ST-T wave
changes.
Compared to the previous tracing atrial fibrillation is new.
.
ECG Study Date of [**2119-3-29**]  10:25:00 AM
Atrial fibrillation with controlled ventricular response.
Compared to the
previous tracing of [**2119-3-26**] the ST segment depression previously
recorded
is more prominent with T wave inversions in leads I, aVL and
V3-V6 and
ST segment depression in lead II. These findings are consistent
with
acute anterolateral and apical ischemic process. There is left
ventricular
hypertrophy. Followup and clinical correlation are suggested.
.
ECG Study Date of [**2119-3-29**]  1:41:32 PM
Marked sinus bradycardia with occasional A-V conduction and
idioventricular rhythm is new as compared with prior tracing of
[**2119-3-29**]. Followup and clinical correlation are suggested.
.
ECG Study Date of [**2119-3-29**]  1:57:38 PM
Wandering atrial pacemaker and occasional ventricular ectopy.
Compared to the previous tracing of [**2119-3-29**] wandering atrial
pacemaker has appeared.
.
ECG Study Date of [**2119-3-29**]  4:09:12 PM
Sinus rhythm and frequent atrial ectopy and occasional
ventricular ectopy.
Diffuse non-specific ST-T wave changes. Compared to the previous
tracing
of [**2119-3-29**] the rate has increased. The lateral ST segment
changes persist.
Clinical correlation is suggested.
.
ECG Study Date of [**2119-3-30**]  3:09:54 AM
Atrial fibrillation with controlled ventricular response.
Compared to the
previous tracing of [**2119-3-29**] atrial fibrillation with controlled
ventricular response has appeared. The lateral ST-T wave changes
consistent with ischemia have increased. Clinical correlation is
suggested.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2119-4-4**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
.
Urine Culture: Pending
.
CXR:   RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2119-4-4**] 8:17 AM

CHEST (PORTABLE AP)

Reason: Please evaluate for acute pathology such as aspiration

[**Hospital 93**] MEDICAL CONDITION:
78 year old man with vascular dementia, atrial fibrillation, DM,
tachy-brady syndrome, now with cough.
REASON FOR THIS EXAMINATION:
Please evaluate for acute pathology such as aspiration
HISTORY: Diabetes with cough.

FINDINGS: In comparison with study of [**3-31**], respiratory motion
somewhat degrades the image. Enlargement of the cardiac
silhouette persists. The hemidiaphragms are not sharply seen,
though this could merely reflect the respiration of the patient
rather than a true finding. Prominence of central vessels
persists and a pacemaker device remains in place.

No gross evidence of pneumonia on this limited study. A lateral
view would be most helpful if clinically possible.
.
   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2119-4-3**] 2:41 PM

CT HEAD W/O CONTRAST

Reason: Please evaluate for acute pathology
Field of view: 25

[**Hospital 93**] MEDICAL CONDITION:
78 year old man with vascular dementia, A. Fib, DM, tachy-brady
syndrome s/p PPM w/ altered mental status
REASON FOR THIS EXAMINATION:
Please evaluate for acute pathology
CONTRAINDICATIONS for IV CONTRAST: Kidney function

ROUTINE UNENHANCED HEAD CT

HISTORY: Vascular dementia, diabetes, altered mental status.

Comparison is made with [**2119-3-31**].

FINDINGS:

The study is motion degraded. Within limits of the examination,
no acute infarction or hemorrhage is seen. There are extensive
small vessel ischemic sequelae in the subcortical and
periventricular white matter. Bilateral basal ganglion lacunes
are seen.
Ventricles are unchanged.
IMPRESSION:

Study limited by motion, no definite acute abnormality is seen.
MRI would be more sensitive for detection of acute ischemia.
.

Brief Hospital Course:
A/P: 78M IDDM, tachy brady syndrome, s/p PPM placement and s/p
recent lacunar infarct, s/p cardioversion for a fib became
bradycardic / hypotensive- tx to CCU, now hemodynamically stable
and called out to floor w/ active issues as R trunk superficial
hematoma and anemia related to this as well as acute on chronic
renal failure.
.
#Rhythm: He was in atrial fibrillation upon admission.  Given
his reduced functional capacity, it was though he might benefit
from cardioversion and short term anticoagulation, especially if
he is in a controlled setting like rehab or skilled nursing
facility to decrease risk of fall.  Heparin was started, as was
amiodarone.  He underwent cardioversion, which was complicated
by bradycardia and hypotension, with pacemaker firing at 40bpm.
He spent three days in the PACU, the duration extended because
of medication-related mental status changes.  He stabilized and
returned to the floor.  He also did not remain in NSR, but
reverted to afib, at which time anticoagulation and amiodarone
was stopped. The decision to stop anticoagulation was made with
discussions with his family.  His pacemaker was adjusted to fire
at 50 bpm given his hypotension during the episode.  His aspirin
was increased to 325mg qday.  His rate control continued with
carvedilol.
.
#CAD: He was transferred from the OSH for cardiac
catheterization given his elevated enzymes and decrease in EF on
ECHO.  He did not undergo cath at [**Hospital1 18**] because it was felt that
medical management would be more appropriate in a patient with
this many comorbidities.  He was given aspirin as above as well
as lipitor.
.
#Pump: (LVEF>55%) w/ LV diastolic dysfunction.  He had a chest
xray consistent with pulmonary edema in the PACU and he diuresed
impressively with IV lasix.  He was continued on carvedilol,
though his ace-inhibitor was held because of his worsening renal
failure.
.
# Anemia- likely secondary to superficial hematoma and in the
setting of cardioversion in the PACU. HCT improved with
transfusion of one unit of pRBCs back to his baseline during the
stay of 30 or greater.
.
#neuro: He had focal weakness upon admission, old facial droop,
and poor mental status.  Per neurology, his symptoms/signs are
likely due at least in part to lacunar infarct, pure motor of
internal capsule. CT negative for bleed x 4 here. No MRI given
pacer. His mental status continued to wax and wane, and he was
though possibly to be encephalopathic from meds plus acute
illness.  He likely has a degree of dementia, and his symptoms
can partly be attributed to delirium in the setting of changing
environments, acute illness, and medications.  Patient's course
complicated by acute on chronic renal failure [**2-11**] to poor PO
intake, and urinary tract infection.
.
#Acute on chronic renal insufficiency: His creatinine initially
improved upon admission, but worsened after his PACU stay,
possibly related to his episode of hypotension or related to the
IV lasix he received.  His lasix was then held, as was his
ace-inhibitor.
.
#DM: NPH [**Hospital1 **] and ISS
.
#FEN: diabetic/heart healthy diet,
.
#PPx: INR supertherapeutic - sc heparin when it drops below 2,
bowel regimen
.
#Access: PIV
.
While in the ICU patient had multiorgan failure.  Family
meetings were held and the patient was made CMO and died
comfortably on [**2119-4-7**].

Medications on Admission:
Home Meds:
NPH 10 units [**Hospital1 **]
lovastatin 20 qd
calcitriol 0.25 mg q MWF
Lasix 20mg qd
coreg 12.5 po bid
lisinopril 5mg qd
vit d.
asa 325
plavix 75
colace
senna
.
OSH Meds upon transfer:
mucomyst 600mg [**Hospital1 **]
aspirin 325
calcium carbonate 500 tid with meals
calcitriol 0.25 q M/W/F
carvedilol 12.5 [**Hospital1 **]
plavix 75 qday
colace
ferrous sulfate 325 tid
lasix 20 po qday
lisinopril 5 qday
multivitamins
simvastatin 40 vitamin D 400IU daily
NPH 10 [**Hospital1 **]
ssi novolog
nitropaste 2 inch q 4 hrs
tylenol
guaifenesin/dextromethorphan
morphine sulfate 1-2 mg IV q 4 hr prn pain


Discharge Medications:
None, patient expired.

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired.
Primary:
atrial fibrillation s/p failed cardioversion
lacunar infarcts
Acute on Chronic Renal Failure
.
Secondary:
IDDM
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)


Discharge Condition:
Expired.

Discharge Instructions:
Expired

Followup Instructions:
Expired
{"Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Diastolic heart failure, unspecified,Chronic kidney disease, Stage IV (severe),Encephalopathy, unspecified,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acidosis,Bacteremia,Subendocardial infarction, subsequent episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy,Abnormality of gait,Hemorrhage, unspecified,Other iatrogenic hypotension,Bell's palsy,Shock therapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anticoagulants causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nonspecific low blood pressure reading,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Other psoriasis,Retention of urine, unspecified,Personal history of tobacco use,Fitting and adjustment of cardiac pacemaker,Cataract extraction status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"}


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: xfer from [**Location (un) **], ? new afib

PRESENT ILLNESS: 78yo M, dizziness with PMH of IDDM, afib not on coumadin (GIB,
frequent falls), bradycardia s/p pacer, diastolic CHF with EF
55%, chronic microvascular infarcts who presented to an OSH
after falling at home. He reports to me that his legs felt weak
and then he lost consciousness. He denied lightheadedness, chesp
pain, palpitations, loss of bowel/bladder, though per OSH notes,
he reportedly had dizziness and one second of chest pain before
falling. He endorses orthopnea, chronic SOB, denies PND. Per
OSH, he was down for roughly one hour. In the OSH, he had a
negative head CT, EKGs showed anterolateral ST-TW changes, and
he had a CPK of over 1200 with MB 18.4 and TropI of 0.8. An ECHO
showed EF 40-45%. He was started on heparin at some point during
his stay. On [**3-25**], complained of L shoulder pain without N/V,
F/C, SOB, chest discomfort. PE showed large bruise on left
lateral chest wall. Heparin was discontinued. CT scan showed
chest hematoma and lymphnodes suspicious for malignancy. On
[**3-25**], his HCT was 31.7, down from 44 on admission. He was noted
to have an decrease in EF compared to previous ECHOs, so he was
transferred to [**Hospital1 18**] for possible cath. On the floor he denies
chest pain, lightheadedness, but endorses shortness of breath.
.
Has chest wall hematoma.

MEDICAL HISTORY: IDDM
afib, not on coumadin (GIB and frequent falls)
h/o brady, now s/p pacer
diastolic CHF with EF of 55% in [**5-/2118**]
CRI: stage iv, baseline Cr of 2.6-3.0
h/o PPM
bilateral peripheral neuropathy
L sided Bell's palsy
h/o osteo of great Left toe
bilateral cataract surgery
h/o falls (last one beginning of [**2119-3-11**])
Neuro issues, being worked up for possible parkinson's disease
GIB in the setting of diverticulitis
psoriasis
chronic microvascular infarcts (per prior records)

MEDICATION ON ADMISSION: Home Meds:
NPH 10 units [**Hospital1 **]
lovastatin 20 qd
calcitriol 0.25 mg q MWF
Lasix 20mg qd
coreg 12.5 po bid
lisinopril 5mg qd
vit d.
asa 325
plavix 75
colace
senna
.
OSH Meds upon transfer:
mucomyst 600mg [**Hospital1 **]
aspirin 325
calcium carbonate 500 tid with meals
calcitriol 0.25 q M/W/F
carvedilol 12.5 [**Hospital1 **]
plavix 75 qday
colace
ferrous sulfate 325 tid
lasix 20 po qday
lisinopril 5 qday
multivitamins
simvastatin 40 vitamin D 400IU daily
NPH 10 [**Hospital1 **]
ssi novolog
nitropaste 2 inch q 4 hrs
tylenol
guaifenesin/dextromethorphan
morphine sulfate 1-2 mg IV q 4 hr prn pain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.6; BP 135/89; HR 77; RR 18; 100% on 2L
gen: well appearing, nad, pleasant
heent: ncat, mmm, eomi, anicteric sclera
neck: supple, no elevated jvd
chest: poor air movement, bibasilar crackles 1/3 up lung fields,
no wheezes. Large left sided echymosis.
cv: heart irregularly irregular, nl s1/s2, no m/r/g
abd: s/nd/nabs, mild ttp diffusely, no rebound
extr: no c/c/e, 1+ distal pulses
neuro: oriented to person and place, not to time. left sided
facial droop, upper extremity strenth 3+/5 on right, [**3-15**] on
left, LE [**4-15**] left weaker than right. Sensation to light touch
intact throughout. Poor neuro exam d/t cooperation.

FAMILY HISTORY: There is no family history of premature coronary artery disease

SOCIAL HISTORY: Social history is significant for the absence of current tobacco 

### Response:
{"Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Diastolic heart failure, unspecified,Chronic kidney disease, Stage IV (severe),Encephalopathy, unspecified,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Acidosis,Bacteremia,Subendocardial infarction, subsequent episode of care,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Encounter for palliative care,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy,Abnormality of gait,Hemorrhage, unspecified,Other iatrogenic hypotension,Bell's palsy,Shock therapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anticoagulants causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nonspecific low blood pressure reading,Long-term (current) use of insulin,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Other psoriasis,Retention of urine, unspecified,Personal history of tobacco use,Fitting and adjustment of cardiac pacemaker,Cataract extraction status,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits"}
