CHIEF COMPLAINT: transferred from OSH for consideration of CABG

PRESENT ILLNESS: 53 y/o M w/ hx CAD with known unvascularized 3VD, chronic
systolic HF with EF 20%, DM, hyperlipidemia, hx of CVA,
asthma/COPD, with recent prolonged hospitalization at [**Hospital1 **] for
inferior MI, cardiogenic shock, respiratory failure, VAP and ARF
who is being transferred from OSH for consideration of CABG.
The pt was admitted to [**Hospital1 498**] on [**9-8**] for IMI and resp failure.
During this hospitalization, he required intermittent dopamine
for cardiogenic shock and was unable to be weaned from vent. He
had a cardiac cath on [**9-25**] demonstrating severe 3VD and global
ventricular dysfunction and an EF 20% and no MR. Because of his
other complicating medical issues, he was determined to not be a
candidate for stenting or CABG. He was discharged to rehab and 2
days later he pt represented to another hospital with 9/10 CP.
His EKGs were reportedly unchanged from prior, had flat cardiac
enzymes and was medically managed with ACEI, lipitor, but no BB.
 Pt was not able to be weaned from vent so was transferred back
to rehab after having a trach and PEG placed. He was either then
discharged or signed out AMA from rehab.
.
He then presented to [**Hospital1 10478**] ED early this am with severe
respiratory distress and chest pain, failed BIPAP, and required
intubation. Prior to intubation, the pt had an episode of black
coffee ground emesis. A NGL lavage was performed with aspiration
of dark material that was guaiac positive. His Hct dropped from
36.9 --> 30.5.  He had diffuse pulm infiltrates that improved
with 1.5 L diuresis but briefly dropped his pressures to the
80s.
.
On review of symptoms, he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: # CAD with known 3VD
- was not revacularized [**1-31**] complicating medical issues
including not being able to quit smoking
# DM
# Hyperlipidemia
# Hx o CVA
# Asthma/COPD
# Disabled [**1-31**] DM and CVA

MEDICATION ON ADMISSION: ASA 325mg daily
lipitor 40mg daily
ISS, no standing
prednisone 20 mg daily
bumex 1mg [**Hospital1 **]
metoprolol ?mg daily
flomax 0.4 mg daily
prevacid 30mg daily
coumadin 9mg daily
flonase nasal spray [**Hospital1 **]
fish oil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.9, BP 114/59, HR 71, RR 24, O2 100% on on AC FiO2 0.50
RR 16 TV 500  PEEP 5
Gen: WDWN middle aged male, intubated, sedated but able to
respond appropriately to commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi. Decreased BS b/l at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

FAMILY HISTORY: NC

SOCIAL HISTORY: Social history is significant for the prescence of current
tobacco use. Pt does use unknown amount of alcohol.
Acute myocardial infarction of inferoposterior wall, initial episode of care,Acute kidney failure, unspecified,Other postoperative infection,Mechanical complication of gastrostomy,Other pulmonary insufficiency, not elsewhere classified,Chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Other disorders of muscle, ligament, and fascia,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified
AMI inferopost, initial,Acute kidney failure NOS,Other postop infection,Gastrostomy comp - mech,Other pulmonary insuff,Chr systolic hrt failure,Crnry athrscl natve vssl,Muscle/ligament dis NEC,Anemia NOS,DMII wo cmp nt st uncntr,Chronic obst asthma NOS
Admission Date:  [**2166-11-21**]              Discharge Date:   [**2166-12-24**]

Date of Birth:  [**2113-11-16**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
transferred from OSH for consideration of CABG

Major Surgical or Invasive Procedure:
CABG x5 (LIMA>LAD, SVG>DIAG, SVG>RAMUS>YGRAFT>OM, SVG>PDA) [**12-12**]


History of Present Illness:
53 y/o M w/ hx CAD with known unvascularized 3VD, chronic
systolic HF with EF 20%, DM, hyperlipidemia, hx of CVA,
asthma/COPD, with recent prolonged hospitalization at [**Hospital1 **] for
inferior MI, cardiogenic shock, respiratory failure, VAP and ARF
who is being transferred from OSH for consideration of CABG.
The pt was admitted to [**Hospital1 498**] on [**9-8**] for IMI and resp failure.
During this hospitalization, he required intermittent dopamine
for cardiogenic shock and was unable to be weaned from vent. He
had a cardiac cath on [**9-25**] demonstrating severe 3VD and global
ventricular dysfunction and an EF 20% and no MR. Because of his
other complicating medical issues, he was determined to not be a
candidate for stenting or CABG. He was discharged to rehab and 2
days later he pt represented to another hospital with 9/10 CP.
His EKGs were reportedly unchanged from prior, had flat cardiac
enzymes and was medically managed with ACEI, lipitor, but no BB.
 Pt was not able to be weaned from vent so was transferred back
to rehab after having a trach and PEG placed. He was either then
discharged or signed out AMA from rehab.
.
He then presented to [**Hospital1 10478**] ED early this am with severe
respiratory distress and chest pain, failed BIPAP, and required
intubation. Prior to intubation, the pt had an episode of black
coffee ground emesis. A NGL lavage was performed with aspiration
of dark material that was guaiac positive. His Hct dropped from
36.9 --> 30.5.  He had diffuse pulm infiltrates that improved
with 1.5 L diuresis but briefly dropped his pressures to the
80s.
.
On review of symptoms, he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

Past Medical History:
# CAD with known 3VD
- was not revacularized [**1-31**] complicating medical issues
including not being able to quit smoking
# DM
# Hyperlipidemia
# Hx o CVA
# Asthma/COPD
# Disabled [**1-31**] DM and CVA

Social History:
Social history is significant for the prescence of current
tobacco use. Pt does use unknown amount of alcohol.

Family History:
NC

Physical Exam:
VS: T 98.9, BP 114/59, HR 71, RR 24, O2 100% on on AC FiO2 0.50
RR 16 TV 500  PEEP 5
Gen: WDWN middle aged male, intubated, sedated but able to
respond appropriately to commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi. Decreased BS b/l at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP



Pertinent Results:
EKG demonstrated sinus tachycardia @ 105 bpm, nl axis, nl
intervals, [**Street Address(2) 4793**] elevation III, 0.[**Street Address(2) 1755**] depressions I, aVL,
TWI I, aVL, V5-6, LBBB with no significant change compared with
prior dated [**11-21**] at 4 am.
.
[**11-22**] cardiac cath
BRIEF HISTORY:
The patient is a 53 yo male transferred from an outside hospital
with an
NSTEMI, congestive heart failure now intubated with known severe
three
vessel disease and transferred for CABG. The patient is now s/p
PEA
arrest on [**2166-11-22**].
.
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV,  unstable.
Prior
MI.
.
PROCEDURE:
Right Heart Catheterization: was performed by percutaneous entry
of the
left femoral vein, using a 7 French pulmonary wedge pressure
catheter,
advanced to the PCW position through an 8 French introducing
sheath.
Cardiac output was measured by the Fick method.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a Cardiac Assist 9 French 30cc wire guided
catheter,
inserted via the left femoral artery.
Peripheral Imaging was performed.
Conscious Sedation:  was provided with appropriate monitoring
performed by
a member of the nursing staff.
.
HEMODYNAMICS RESULTS BODY SURFACE AREA:  1.86 m2
  HEMOGLOBIN: 9.1 gms %
  FICK
**PRESSURES
RIGHT VENTRICLE {s/ed} 52/14
PULMONARY ARTERY {s/d/m} 56/32/43
PULMONARY WEDGE {a/v/m} 30/31/28
AORTA {s/d/m} 103/73/85
**CARDIAC OUTPUT
HEART RATE {beats/min} 103
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 37
CARD. OP/IND FICK {l/mn/m2} 6.3/3.4
**RESISTANCES
PULMONARY VASC. RESISTANCE 191
.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA   NORMAL
2) MID RCA   DISCRETE 70
2A) ACUTE MARGINAL   NORMAL
3) DISTAL RCA   DISCRETE 100
4) R-PDA   DISCRETE 80
.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN   NORMAL
6) PROXIMAL LAD   DISCRETE 70
6A) SEPTAL-1   NORMAL
7) MID-LAD   NORMAL
8) DISTAL LAD   DISCRETE 80
9) DIAGONAL-1   DISCRETE 80
11) INTERMEDIUS   DISCRETE
12) PROXIMAL CX   DISCRETE 100
13) MID CX   DISCRETE 100
13A) DISTAL CX   DISCRETE 100
.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour50 minutes.
Arterial time = 0 hour46 minutes.
Fluoro time = 7.6 minutes.
Contrast injected:
          Non-ionic low osmolar (isovue, optiray...), vol 70 ml,
Indications - Renal
Anesthesia:
          1% Lidocaine subq.
Anticoagulation:
          Heparin 0 units IV
Cardiac Cath Supplies Used:
          4F CORDIS, MULTIPACK
          8F ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC
          - ALLEGIANCE, CUSTOM STERILE PACK
.
COMMENTS:
1. Coronary angiography of this right dominant system revealed a
normal
LMCA, 70% proximal stenosis in the LAD, 80% distal LAD stenosis
and 80%
stenosis in D1. The LCX was totally occluded. The RCA had a 70%
mid
stenosis, 80% stenosis of the right PDA and total occlusion
after the
PDA.
.
2. Peripheral arteriography revealed a right iliac artery that
was
patent and a left iliac artery with a 60% stenosis without a
gradient of
flow.
.
3. Hemodynamics revealed low-normal systemic arterial pressures
with an
SBP of 103 mm Hg. The RVEDP was elevated at 14 and the PASP was
56. The
PCWP was 28 mm Hg for which 40 mg IV lasix was given.
.
4. An IABP was placed without complication in the left groin.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2 . Acute infero-posterior myocardial infarction, managed by
IABP.

Echo [**12-9**]
The left atrium is normal in size. The left ventricular cavity
size is normal. There is moderate regional left ventricular
systolic dysfunction with inferior and lateral akinesis
(estimated ejection fraction ?30-35%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.

No vegetation seen (cannot exclude; views are technically
suboptimal)

Compared with the prior study (images reviewed) of [**2166-11-22**],
there is no definite change.
[**12-12**]
PRE CPB Normal right ventricular systolic function. Significant
left ventricular enlargement. Left ventricle with moderate
global dysfunction and severe hypokinesis of all but the basal
septal, anterior, and inferior walls. The apex is essentially
akinetic. No thrombus is seen in the left ventricular apex. The
left ventricular ejection fraction is about 15-20% at best.
There is spontaneous echo contrast seen in the left atrium and
left atrial appendage. No thrombus is seen in either of these
locations. The mitral leaflets are mildly thickened and there is
trace mitral regurgitation. There is no aortic regurgitation. A
fibrinous echodensity is seen extending from the wall of the
proximal ascending aorta to the left or non-coronary cusp of the
aortic valve consistent with a fibroelastoma. There is mild
tricuspid regurgitation. There is mild atheromatous disease seen
in the descending thoracic aorta and aortic arch.
CT ABDOMEN W/CONTRAST  [**2166-12-4**] 1:44 PM
ABDOMEN: Incompletely imaged small to moderate bilateral pleural
effusions, (left greater than right) are associated with
atelectasis. The liver, spleen, pancreas, and adrenal glands
appear unremarkable. The gallbladder is present. Mild right
perinephric and fat stranding is a nonspecific finding, as the
kidneys enhance symmetrically, without hydronephrosis.
.
A gastrostomy tube balloon lies in the left upper quadrant
musculature, and a moderate amount of air tracks along the
musculature inferiorly. No discrete fluid collection is seen.
The stomach is partially filled with contrast and there is no
evidence of oral contrast extravasation into the peritoneum or
into the subcutaneous tissues.
.
There is no free intraperitoneal air, bowel dilatation or
ascites within the abdomen or pelvis. Atheromatous calcification
of the distal aorta and iliac arteries is moderate, without
aneurysm.
.
PELVIS: A Foley catheter and air is seen in the bladder. The
prostate gland is unremarkable. The rectum and sigmoid colon are
within normal limits.
.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic
lesions. A sclerotic focus in the right femoral head has a
nonaggressive appearance.
.
IMPRESSION:
1. Gastrostomy tube balloon in the left upper quadrant soft
tissues with associated soft tissue air moderate air but no
evidence of oral contrast extravasation or abscess.
2. Bilateral pleural effusions.
.
[**12-6**] Pathology
.
Soft tissue, posterior rectus sheath, "abdominal wall abscess"
(A,B):
Fibroadipose tissue and skeletal muscle with intense acute
inflammation and necrosis.
.
Stains for micro-organisms will be performed and the results
issued in a separate addendum.
.
Clinical:  53 year old man with abdominal wall abscess, rule out
necrotizing fascitis, Specimen submitted, posterior rectus
sheath.
.
Gross: The specimen is received fresh labeled with "[**Known firstname **]
[**Known lastname 33733**]" the medical record number and "posterior rectus
sheath". It consists of multiple fragments of tan soft red
tissue measuring 3 x 2.5 x 1 cm in aggregate.  A portion of the
tissue appears necrotic with areas of cautery. The specimen is
entirely submitted in A-B.
.
Microbiology
.
[**2166-12-6**] 1:00 pm TISSUE     Site: ABDOMEN      ABDOMINAL WALL
TISSUE.
.
**FINAL REPORT [**2166-12-10**]**
.   GRAM STAIN (Final [**2166-12-6**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) 971**] [**Last Name (NamePattern1) **] @ 2225 ON [**12-6**] - FA6B.
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   YEAST(S).
   TISSUE (Final [**2166-12-10**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      ENTEROCOCCUS SP..    MODERATE GROWTH.
      [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.    MODERATE
GROWTH.
      LACTOBACILLUS SPECIES.    MODERATE GROWTH.
      GAMMA(I.E. NON-HEMOLYTIC) STREPTOCOCCUS.    SPARSE GROWTH.

                             SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
PENICILLIN------------     8 S
VANCOMYCIN------------   <=1 S

Urine Cx [**12-8**] Yeast >100,000


Brief Hospital Course:
Pt was admitted to the CCU at [**Hospital1 18**] for further work-up and
treatment of his medical condition. He ruled in for an NSTEMI
with severe LV dysfunction per TTE. On [**11-22**] he experienced
acute dyspnea and hypotension suffering PEA arrest. He was
intubated and resuscitated with multiple rounds of epi/atropine.
Dopamine was started for hypotension. His arrest was thought due
to global cardiac ischemia/cardiogenic shock. He was put on
broad spectrum antibiotics given leukocytosis and potential
sepsis and ? aspiration. He was also thought to have an UGIB
given his melena, though GI did not think his bleed was acute.
He underwent cardiac cath on [**11-22**] showing severe 3VD and
elevated filling pressures. IABP and swan were placed. He
required PRBCs given his anemia. Pressors were eventually
weaned. Balloon pump was kept in for a week. Pt kept on asa,
heparin, plavix, metoprolol, statin, and isordil tid as
pressures would tolerate. Pt had several episodes of
tachycardia, tachypnea, and hypertension that would induce ST
depressions on ant leads of ECG. These changes would dissipate
with control of BP and HR. Fever, leukocytosis, question of
impaired anoxic encephalopathy s/p PEA arrest, and question of
GI bleed initially prevented CABG. Fever spiked [**12-4**] vanco/zosyn
[**Date range (1) 69839**].  PEG from OSH, became tender and tube feeds were
causing patient pain. [**12-6**] pt was taken to OR for exploration of
PEG site and removal of rectus sheath abscess. VAC was placed.
Fever resolved. Mild leukocytosis of 11.5 remained day of
surgery. Pt was extubated on [**12-3**] for several day period and
showed no signs of anoxic brain injury. He was reintubated on
[**12-7**] for flash pulmonary edema and respiratory distress. Kept
intubated up until CABG. On admit there was question of GI
bleed, but patient was on heparin for greater than a week with
out significant hct drop. Pt noted to have free air on CXR [**12-5**],
but benign abd exam. PRN blood transfusions were given. Plavix
was discontinued several days before surgery. On [**2166-12-12**] he
underwent CABG x 5. He was transferred to the ICU on levophed,
milrinone, insulin and propofol. on [**12-15**] he was extubated and
reintubated for agitation. Seen by ID and pan-scanned.
Thoracentesis for 700 cc performed on [**12-17**]. Extubated again on
[**12-18**]. He was transferred to the floor on [**12-21**]. PICC placed on
[**12-22**]. He was ready for discharge to rehab on POD #12.

Medications on Admission:
ASA 325mg daily
lipitor 40mg daily
ISS, no standing
prednisone 20 mg daily
bumex 1mg [**Hospital1 **]
metoprolol ?mg daily
flomax 0.4 mg daily
prevacid 30mg daily
coumadin 9mg daily
flonase nasal spray [**Hospital1 **]
fish oil

Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Zosyn 4.5 gram Recon Soln [**Last Name (STitle) **]: One (1)  Intravenous every six
(6) hours for 4 weeks: started [**12-18**] - through [**2167-1-15**].
7. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q 24H (Every 24 Hours) for 4 weeks: started [**12-18**] -
through [**2167-1-15**].
8. Fluconazole 200 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q24H (every
24 hours) for 4 weeks: started [**12-18**] - through [**2167-1-15**].
9. Carvedilol 3.125 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO BID (2
times a day).
10. Prednisone 20 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
11. Insulin Glargine 100 unit/mL Solution [**Month/Day/Year **]: Fifteen (15)
units Subcutaneous at bedtime.
12. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: per sliding scale
Subcutaneous four times a day.
13. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day for 1
weeks: then reassess need for diuresis.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
[**Hospital1 **]: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 1 weeks: while on lasix.
16. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day): SQ.
17. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q4H (every 4 hours).
18. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution [**Hospital1 **]: One (1)
 Inhalation Q4H (every 4 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 **]

Discharge Diagnosis:
CAD now s/p CABG
PMH:
DM, HTN, CAD, COPD, Lipids, CVA, smoker, EtOH, VRE by rectal
swab


Discharge Condition:
Good.


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 Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Trauma Surgeon) in [**12-31**] weeks for wound check
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**First Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] after discharge from rehab


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

Completed by:[**2166-12-24**]
{'Acute myocardial infarction of inferoposterior wall, initial episode of care,Acute kidney failure, unspecified,Other postoperative infection,Mechanical complication of gastrostomy,Other pulmonary insufficiency, not elsewhere classified,Chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Other disorders of muscle, ligament, and fascia,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified'}


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: transferred from OSH for consideration of CABG

PRESENT ILLNESS: 53 y/o M w/ hx CAD with known unvascularized 3VD, chronic
systolic HF with EF 20%, DM, hyperlipidemia, hx of CVA,
asthma/COPD, with recent prolonged hospitalization at [**Hospital1 **] for
inferior MI, cardiogenic shock, respiratory failure, VAP and ARF
who is being transferred from OSH for consideration of CABG.
The pt was admitted to [**Hospital1 498**] on [**9-8**] for IMI and resp failure.
During this hospitalization, he required intermittent dopamine
for cardiogenic shock and was unable to be weaned from vent. He
had a cardiac cath on [**9-25**] demonstrating severe 3VD and global
ventricular dysfunction and an EF 20% and no MR. Because of his
other complicating medical issues, he was determined to not be a
candidate for stenting or CABG. He was discharged to rehab and 2
days later he pt represented to another hospital with 9/10 CP.
His EKGs were reportedly unchanged from prior, had flat cardiac
enzymes and was medically managed with ACEI, lipitor, but no BB.
 Pt was not able to be weaned from vent so was transferred back
to rehab after having a trach and PEG placed. He was either then
discharged or signed out AMA from rehab.
.
He then presented to [**Hospital1 10478**] ED early this am with severe
respiratory distress and chest pain, failed BIPAP, and required
intubation. Prior to intubation, the pt had an episode of black
coffee ground emesis. A NGL lavage was performed with aspiration
of dark material that was guaiac positive. His Hct dropped from
36.9 --> 30.5.  He had diffuse pulm infiltrates that improved
with 1.5 L diuresis but briefly dropped his pressures to the
80s.
.
On review of symptoms, he denies any prior history of deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: # CAD with known 3VD
- was not revacularized [**1-31**] complicating medical issues
including not being able to quit smoking
# DM
# Hyperlipidemia
# Hx o CVA
# Asthma/COPD
# Disabled [**1-31**] DM and CVA

MEDICATION ON ADMISSION: ASA 325mg daily
lipitor 40mg daily
ISS, no standing
prednisone 20 mg daily
bumex 1mg [**Hospital1 **]
metoprolol ?mg daily
flomax 0.4 mg daily
prevacid 30mg daily
coumadin 9mg daily
flonase nasal spray [**Hospital1 **]
fish oil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.9, BP 114/59, HR 71, RR 24, O2 100% on on AC FiO2 0.50
RR 16 TV 500  PEEP 5
Gen: WDWN middle aged male, intubated, sedated but able to
respond appropriately to commands.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 10 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  no m/r/g appreciated
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi. Decreased BS b/l at bases
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP

FAMILY HISTORY: NC

SOCIAL HISTORY: Social history is significant for the prescence of current
tobacco use. Pt does use unknown amount of alcohol. 

### Response:
{'Acute myocardial infarction of inferoposterior wall, initial episode of care,Acute kidney failure, unspecified,Other postoperative infection,Mechanical complication of gastrostomy,Other pulmonary insufficiency, not elsewhere classified,Chronic systolic heart failure,Coronary atherosclerosis of native coronary artery,Other disorders of muscle, ligament, and fascia,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic obstructive asthma, unspecified'}
