CHIEF COMPLAINT: shortness of breath, red-tinged sputum production

PRESENT ILLNESS: This is a 76 year-old [**First Name3 (LF) 24075**]-speaking male with h/o DM,
infarct-related cardiomyopathy, CHF (most recent EF of 50% in
[**Month (only) 359**], nadir of 20%), CAD s/p CABG x 2 ([**2091**], [**2099**]) &
biventricular ICD ([**2110**]), and chronic atrial fibrillation (on
Warfarin, INR 10.1 on presentation), severe MR s/p MVR in [**2115**],
s/p AVN ablation in [**2114**], history of CRI with intolerance to ACE
inhibitors and ARBs, history of carotid artery disease not
amenable to operation, and a recent history cellulitis and
erysipelas (finished a course of doxycycline at end of [**Month (only) **])
presents with increasing dyspnea for 1 day of worsening of SOB
consistent with prior chf exacerbations. Denies fever, chills,
nausea, vomiting, cp or back pain.
.
Of note the patient has had three recent admissions for similar
symptoms of dyspnea on exertion which improved with diuresis.
(d/c [**6-8**], [**7-18**], [**9-7**]). During his most recent admission, a CT
scan was done and demonstrated generalized additional
abnormality involving both lungs with associated areas of
ground-glass opacity, which had slightly progressed since the
prior study.  Overall, radiographically likely represented
worsening pulmonary edema, interstitial lung disease could not
be ruled out.  There were a few pulmonary nodules, have been
stable since [**2115-4-25**].  There is cardiomegaly involving the
left atrium and ventricle, pulmonary arterial hypertension as
well as cholelithiasis.  Echocardiogram from that admission
demonstrated an EF of 50% with a moderately dilated LV cavity
mildly depressed LVEF and the normal RV and normal right
ventricle aorta, minimal AS, MR, 2+ MR [**First Name (Titles) 151**] [**Last Name (Titles) **] that was
estimated as moderate.  Of note, eccentric jet of at least 2+
mitral regurgitation was seen and due to acoustic shadowing, the
severity of MR could have been underestimated per report.
Spirometry and DLCO at that time also demonstrated moderate
restrictive ventilator deficit with a severe gas exchange and no
significant response with bronchodilator testing.  Most recent
spirometry testing is stable.  FVC of 1.29, 42% predicted, FEV1
is 0.94, 47% predicted; and FEV1/FVC ratio is 73, 111%
predicted. Overall, he has a stable restrictive ventilatory
deficit, no DLCO was done.  He saw pulmonary on [**2119-10-5**], who
felt that he does not have PFTs supporting COPD and stopped his
Advair and Spiriva.  They noted thrush that is likely secondary
to the Advair and gave him a 7 day course of nystatin.  He saw
his PCP [**Last Name (NamePattern4) **] [**2119-10-16**], who started him on Clindamycin 300 mg QID
for 14 days for recurrent cellulitis, however, he was not
tolerating the abx.  He was placed on Bactrim for 10 days (last
day - [**2119-11-9**]).  He was also started on Miralax for 17 g daily
for constipation.  Today, he was seen by visiting nurse today
for INR check but was found to be in CHF exacerbation (SOB,
edematous, 02 sat 87% on 3L, crackles 1/2 up. BP 110-120. Wife
reports that he has been coughing up dark sputum, not sleeping
at baseline 2 pillows at night due to PND. No fevers).  He was
referred to the ED by Dr. [**Last Name (STitle) 1911**].
.
In the ED: intial vitals were: 97.1 70 126/79 40 74% 3L NC. Labs
were significant for BNP 6843 and trop 0.02 (baseline), Cr 3.0
(baseline of 1.8), INR 10.1 and Hct 28.7. Physical exam was
significant were crackles at the bilateral lower lung fields and
erythema of the b/l lower extremity. A chest xray demonstrated
moderate congestive heart failure.   Guaiac was negative.  DRE
was notable for mixture of bright red blood and brown stool -> ?
anal lesions.  His saturation improved with BiPAP, however, his
sats fell to the 90 and he developed retractions on trial off
BiPAP.  He was given aspirin, lasix 40 x1, sl NG x2.  Vitals on
transfer: 70 107/74 33 100% on non-rebreather.
.
On arrival to the floor, initial vitals are 70 99/42 25 100%
sat. He is accompanied by wife and son and is dyspneic on exam.
His wife and son translated.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: s/p CABG in [**2091**] and [**2099**] (SVG-LAD, SVG-OM1)
- PERCUTANEOUS CORONARY INTERVENTIONS:  Successful Cypher
stenting of the mid-LCX [**2110**]
- PACING/ICD:  biventricular ICD implantation in [**2110**]
.
3. OTHER PAST MEDICAL HISTORY:
- Chronic atrial fibrillation status post AV nodal ablation in
[**2114**]
- Chronic renal insufficiency with intolerance to ACE inhibitors
and ARBs (baseline creatinine prior to admit 1.8)
- mitral valve annuloplasty in in [**2115**] (size 28 [**Doctor Last Name **] Physio
ring)
- Diabetes type 2, on insulin
- infarcted cardiomyopathy
- CVA in [**2115**]

MEDICATION ON ADMISSION: Confirmed
- Home Oxygen 2L NC at rest. 4L Nasal cannula on activity.
- insulin glargine 18 Units Subcutaneous at bedtime
- ferrous sulfate 300 mg (60 mg iron) Tablet PO DAILY
- torsemide 80 mg Tab by mouth twice a day
- Carvedilol 9.375 mg Tab by mouth twice a day
- sulfamethoxazole-trimethoprim 800 mg-160 mg Tab twice daily
(thursday last)
- Aspirin 81 mg Tab by mouth once a day
- hydralazine 25 mg Tab three times daily
- Simvastatin 40 mg Tab 1 Tablet(s) by mouth QPM
- isosorbide mononitrate ER 30 mg 24 hr Tab by mouth daily
- spironolactone 25 mg Tab 1 Tablet(s) by mouth once a day
- Docusate Sodium 100 mg Cap twice a day
- warfarin 4 mg on monday, 2mg on other days
- ranitidine 150 mg Tab 1 Tablet(s) by mouth twice a day

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: PHYSICAL EXAMINATION (on admission):
.
VS: T=98 BP=99/42 HR=70 RR=20 O2 sat= 100% on nrb
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP to 10cm.
CARDIAC: RR, normal S1, S2. [**1-30**] harsh blowing murmur heard best
at the apex but radiating to the carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were labored, accessory muscle use. Stable lung exam, trace
crackles just on the left side, good air movement despite lower
saturations.
ABDOMEN: Soft, NTND. No HSM or tenderness, BS present
EXTR: 3+ edema to the ankle, erythematous, + peteche. No joint
tenderness.
SKIN: LE erythema c/w venous stasis changes.
PULSES:
Right: Carotid 2+ 1+ DP 1+ PT 2+ radial 2+
Left: Carotid 2+ DP 1+ PT 1+ radial 2+

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Married with two sons. [**Name (NI) **] is retired from construction work.
- He came from [**Country 5881**] >30 yrs ago and only speaks [**Country 24075**] but wife
can communicate well in both [**Name (NI) 24075**] and English.
- Former smoker (smoked 4ppd, quit 12 years ago) for ~120pack-yr
history
- Occasional EtOH.
- Denies other drugs.
- employment: exposure to asbestos in [**Name (NI) 24075**] navy, 41 years in
construction.
Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Mixed acid-base balance disorder,Other specified alveolar and parietoalveolar pneumonopathies,Acquired coagulation factor deficiency,Other primary cardiomyopathies,Other hemoptysis,Cellulitis and abscess of leg, except foot,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage III (moderate),Other secondary thrombocytopenia,Aortocoronary bypass status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Venous (peripheral) insufficiency, unspecified,Other dependence on machines, supplemental oxygen,Spontaneous ecchymoses,Other chronic pulmonary heart diseases,Gross hematuria,Other specified cardiac device in situ,Sulfonamides causing adverse effects in therapeutic use
Acute respiratry failure,Ac/chr syst/dia hrt fail,Acute kidney failure NOS,Mixed acid-base bal dis,Alveol pneumonopathy NEC,Acq coagul factor defic,Prim cardiomyopathy NEC,Hemoptysis NEC,Cellulitis of leg,Delirium d/t other cond,Chr kidney dis stage III,Sec thrombocytpenia NEC,Aortocoronary bypass,Atrial fibrillation,Long-term use anticoagul,Hy kid NOS w cr kid I-IV,History of tobacco use,Anemia in chr kidney dis,DMII renl nt st uncntrld,Venous insufficiency NOS,Depend-supplement oxygen,Spontaneous ecchymoses,Chr pulmon heart dis NEC,Gross hematuria,Status oth spcf crdc dvc,Adv eff sulfonamides
Admission Date:  [**2119-11-6**]              Discharge Date:   [**2119-11-28**]

Date of Birth:  [**2043-7-9**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
shortness of breath, red-tinged sputum production

Major Surgical or Invasive Procedure:
Bedside bronchoscopy with bronchoalveolar lavage
Ebdotracheal intubation and ventilation
Nasogastric tube placement


History of Present Illness:
This is a 76 year-old [**First Name3 (LF) 24075**]-speaking male with h/o DM,
infarct-related cardiomyopathy, CHF (most recent EF of 50% in
[**Month (only) 359**], nadir of 20%), CAD s/p CABG x 2 ([**2091**], [**2099**]) &
biventricular ICD ([**2110**]), and chronic atrial fibrillation (on
Warfarin, INR 10.1 on presentation), severe MR s/p MVR in [**2115**],
s/p AVN ablation in [**2114**], history of CRI with intolerance to ACE
inhibitors and ARBs, history of carotid artery disease not
amenable to operation, and a recent history cellulitis and
erysipelas (finished a course of doxycycline at end of [**Month (only) **])
presents with increasing dyspnea for 1 day of worsening of SOB
consistent with prior chf exacerbations. Denies fever, chills,
nausea, vomiting, cp or back pain.
.
Of note the patient has had three recent admissions for similar
symptoms of dyspnea on exertion which improved with diuresis.
(d/c [**6-8**], [**7-18**], [**9-7**]). During his most recent admission, a CT
scan was done and demonstrated generalized additional
abnormality involving both lungs with associated areas of
ground-glass opacity, which had slightly progressed since the
prior study.  Overall, radiographically likely represented
worsening pulmonary edema, interstitial lung disease could not
be ruled out.  There were a few pulmonary nodules, have been
stable since [**2115-4-25**].  There is cardiomegaly involving the
left atrium and ventricle, pulmonary arterial hypertension as
well as cholelithiasis.  Echocardiogram from that admission
demonstrated an EF of 50% with a moderately dilated LV cavity
mildly depressed LVEF and the normal RV and normal right
ventricle aorta, minimal AS, MR, 2+ MR [**First Name (Titles) 151**] [**Last Name (Titles) **] that was
estimated as moderate.  Of note, eccentric jet of at least 2+
mitral regurgitation was seen and due to acoustic shadowing, the
severity of MR could have been underestimated per report.
Spirometry and DLCO at that time also demonstrated moderate
restrictive ventilator deficit with a severe gas exchange and no
significant response with bronchodilator testing.  Most recent
spirometry testing is stable.  FVC of 1.29, 42% predicted, FEV1
is 0.94, 47% predicted; and FEV1/FVC ratio is 73, 111%
predicted. Overall, he has a stable restrictive ventilatory
deficit, no DLCO was done.  He saw pulmonary on [**2119-10-5**], who
felt that he does not have PFTs supporting COPD and stopped his
Advair and Spiriva.  They noted thrush that is likely secondary
to the Advair and gave him a 7 day course of nystatin.  He saw
his PCP [**Last Name (NamePattern4) **] [**2119-10-16**], who started him on Clindamycin 300 mg QID
for 14 days for recurrent cellulitis, however, he was not
tolerating the abx.  He was placed on Bactrim for 10 days (last
day - [**2119-11-9**]).  He was also started on Miralax for 17 g daily
for constipation.  Today, he was seen by visiting nurse today
for INR check but was found to be in CHF exacerbation (SOB,
edematous, 02 sat 87% on 3L, crackles 1/2 up. BP 110-120. Wife
reports that he has been coughing up dark sputum, not sleeping
at baseline 2 pillows at night due to PND. No fevers).  He was
referred to the ED by Dr. [**Last Name (STitle) 1911**].
.
In the ED: intial vitals were: 97.1 70 126/79 40 74% 3L NC. Labs
were significant for BNP 6843 and trop 0.02 (baseline), Cr 3.0
(baseline of 1.8), INR 10.1 and Hct 28.7. Physical exam was
significant were crackles at the bilateral lower lung fields and
erythema of the b/l lower extremity. A chest xray demonstrated
moderate congestive heart failure.   Guaiac was negative.  DRE
was notable for mixture of bright red blood and brown stool -> ?
anal lesions.  His saturation improved with BiPAP, however, his
sats fell to the 90 and he developed retractions on trial off
BiPAP.  He was given aspirin, lasix 40 x1, sl NG x2.  Vitals on
transfer: 70 107/74 33 100% on non-rebreather.
.
On arrival to the floor, initial vitals are 70 99/42 25 100%
sat. He is accompanied by wife and son and is dyspneic on exam.
His wife and son translated.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: s/p CABG in [**2091**] and [**2099**] (SVG-LAD, SVG-OM1)
- PERCUTANEOUS CORONARY INTERVENTIONS:  Successful Cypher
stenting of the mid-LCX [**2110**]
- PACING/ICD:  biventricular ICD implantation in [**2110**]
.
3. OTHER PAST MEDICAL HISTORY:
- Chronic atrial fibrillation status post AV nodal ablation in
[**2114**]
- Chronic renal insufficiency with intolerance to ACE inhibitors
and ARBs (baseline creatinine prior to admit 1.8)
- mitral valve annuloplasty in in [**2115**] (size 28 [**Doctor Last Name **] Physio
ring)
- Diabetes type 2, on insulin
- infarcted cardiomyopathy
- CVA in [**2115**]

Social History:
- Married with two sons. [**Name (NI) **] is retired from construction work.
- He came from [**Country 5881**] >30 yrs ago and only speaks [**Country 24075**] but wife
can communicate well in both [**Name (NI) 24075**] and English.
- Former smoker (smoked 4ppd, quit 12 years ago) for ~120pack-yr
history
- Occasional EtOH.
- Denies other drugs.
- employment: exposure to asbestos in [**Name (NI) 24075**] navy, 41 years in
construction.


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
PHYSICAL EXAMINATION (on admission):
.
VS: T=98 BP=99/42 HR=70 RR=20 O2 sat= 100% on nrb
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP to 10cm.
CARDIAC: RR, normal S1, S2. [**1-30**] harsh blowing murmur heard best
at the apex but radiating to the carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were labored, accessory muscle use. Stable lung exam, trace
crackles just on the left side, good air movement despite lower
saturations.
ABDOMEN: Soft, NTND. No HSM or tenderness, BS present
EXTR: 3+ edema to the ankle, erythematous, + peteche. No joint
tenderness.
SKIN: LE erythema c/w venous stasis changes.
PULSES:
Right: Carotid 2+ 1+ DP 1+ PT 2+ radial 2+
Left: Carotid 2+ DP 1+ PT 1+ radial 2+

Pertinent Results:
ADMISSION LABS:
.
[**2119-11-6**] 01:35PM BLOOD WBC-7.2 RBC-2.87* Hgb-8.8* Hct-28.7*
MCV-100* MCH-30.7 MCHC-30.7* RDW-19.3* Plt Ct-112*
[**2119-11-6**] 01:35PM BLOOD PT-98.7* PTT-64.3* INR(PT)-10.11*
[**2119-11-6**] 01:35PM BLOOD Glucose-176* UreaN-57* Creat-3.0*#
Na-132* K-5.8* Cl-96 HCO3-24 AnGap-18
[**2119-11-7**] 04:37AM BLOOD ALT-26 AST-63* LD(LDH)-615* CK(CPK)-66
AlkPhos-121 TotBili-1.1
[**2119-11-7**] 04:37AM BLOOD CK-MB-3 cTropnT-0.02*
[**2119-11-6**] 01:35PM BLOOD cTropnT-0.02*
[**2119-11-6**] 01:35PM BLOOD proBNP-6843*
[**2119-11-7**] 04:37AM BLOOD Albumin-3.9 Calcium-8.8 Phos-5.7*#
Mg-3.1* Iron-35*
[**2119-11-7**] 04:37AM BLOOD calTIBC-337 Ferritn-164 TRF-259
[**2119-11-7**] 03:14PM BLOOD C3-116 C4-27
[**2119-11-7**] 05:11AM BLOOD Type-ART pO2-45* pCO2-49* pH-7.39
calTCO2-31* Base XS-3
[**2119-11-6**] 01:41PM BLOOD Lactate-2.3* K-5.1
[**2119-11-7**] 05:11AM BLOOD O2 Sat-73
.
ON DISCHARGE:
[**2119-11-28**] 05:32AM BLOOD WBC-6.0 RBC-2.56* Hgb-7.9* Hct-25.6*
MCV-100* MCH-30.8 MCHC-30.8* RDW-20.9* Plt Ct-164

[**2119-11-28**] 05:32AM BLOOD PT-16.2* PTT-68.6* INR(PT)-1.5*

[**2119-11-28**] 05:32AM BLOOD Glucose-92 UreaN-63* Creat-1.7* Na-142
K-4.3 Cl-103 HCO3-34* AnGap-9

MICROBIOLOGIC STUDIES:
[**2119-11-6**] Blood culture - negative
[**2119-11-6**] Urine culture - negative
[**2119-11-6**] MRSA screen - negative
[**2119-11-7**] Bronchoalveolar lavage - no organisms, no PMNs -
negative
[**2119-11-7**] Broncheal washings - negative for malignancy
[**2119-11-7**] Rapid Respiratory Viral Screen & Culture - negative
[**2119-11-7**] Blood culture - negative
[**2119-11-8**] Blood culture - negative
[**2119-11-8**] Blood culture - negative
[**2119-11-8**] Urine culture - negative
[**2119-11-9**] Blood culutre - negative
[**2119-11-9**] Urine culture - negative
[**2119-11-9**] Sputum culture - no organisms seen; negative
[**2119-11-9**] Blood culture - negative
.
IMAGING STUDIES:
[**2119-11-6**] CHEST (PORTABLE AP) - Patient is status post median
sternotomy, CABG, and mitral valve replacement. A left-sided
AICD device is noted with leads terminating in the right atrium,
right ventricle, and coronary sinus. Mild enlargement of the
cardiac silhouette is redemonstrated, with unchanged tortuosity
of the thoracic aorta. There is perihilar haziness with vascular
indistinctness and diffuse alveolar opacities compatible with
moderate pulmonary edema. No large pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
.
[**2119-11-7**] CT CHEST W/O CONTRAST - Since [**2119-9-12**],
bilateral interstitial thickening and ground-glass opacities
have progressed, new multifocal peribronchial consolidations and
small bilateral pleural effusions, right side more than left,
are concerning for concurrent multifocal lung infection and
pulmonary edema in the background
of pre-existing interstitial abnormalities. Moderate
cardiomegaly, predominantly involving the left [**Doctor Last Name 1754**]. Mild
pulmonary arterial hypertension. Multiple enlarged mediastinal
lymph nodes are stable.
.
[**2119-11-8**] 2D-ECHO - No atrial septal defect is seen by 2D or
color Doppler. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid to distal septum.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the aortic arch and the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. A mitral valve annuloplasty
ring is present. Mild to moderate ([**11-27**]+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion. Mild to moderate mitral regurgitation in
spite of a well seated mitral annuloplasty ring. Moderate
tricuspid regurgitation. Moderate pulmonary arterial systolic
hypertension.
.
[**2119-11-8**] RENAL U.S. PORT - The right kidney measures 10.2 cm and
the left kidney measures 10.2 cm. There is no hydronephrosis. No
perinephric fluid collection is identified. No stone or
suspicious solid mass is seen in either kidney. A cyst is seen
at the upper pole of the right kidney on the posterior margin
measuring 2.4 x 2.2 x 2.4 cm. A cyst is also seen at the lower
pole of the right kidney measuring 1.4 x 1.2 x 0.9 cm. The
urinary bladder could not be assessed as a Foley catheter is in
place.
.
[**2119-11-8**] CT HEAD W/O CONTRAST - There is an unchanged region of
cystic
encephalomalacia in the posterior left parietal lobe resulting
from an old
infarct. This lesion is expectedly associated with volume loss
and ex vacuo dilation of the occipital [**Doctor Last Name 534**] of the left lateral
ventricle. There is a hypoattenuating focus of within the right
corona radiata (2:19), from an old lacunar infarct, also stable
from [**2115**]. There is no evidence of hemorrhage, edema, mass, mass
effect, new infarction, or hydrocephalus. Mild sulcal prominence
is consistent with age-related cerebral cortical atrophy. The
visualized paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. No acute intracranial process. Cystic
encephalomalacia due to an old left posterior parietal infarct.
Old lacunar infarct in the right corona radiata.
.
[**2119-11-9**] EEG - This continuous monitoring continues to show a
diffuse
encephalopathy that does not have any clear focal or
lateralizing
features. There were a few interictal epileptic discharges
identified
by computer algorithm but no sustained seizures.
.
[**2119-11-12**] CXR - Since the prior radiograph there was interval
insertion of right internal jugular line with its tip
terminating in the level of cavoatrial junction. There is no
evidence of pneumothorax or apical hematoma. The ET tube tip is
4.3 cm above the carina. The replaced mitral valve and the
pacemaker leads are in unchanged position. Overall there is no
change in widespread parenchymal opacities, bibasal atelectasis
and pleural effusion.

[**2119-11-24**]   Radiology CT HEAD W/O CONTRAST
1. No acute intracranial process.
2. Stable cystic encephalomalacia secondary to old left
posterior parietal
infarct.
3. Stable right corona radiata lacune.

 CHEST (PORTABLE AP) Study Date of [**2119-11-25**] 11:54 AM
Bedside frontal radiograph centered at the diaphragm shows
nasogastric tube ending in the proximal duodenum, and the distal
portions of a transvenous right ventricular pacer defibrillator
and left ventricular pacer leads, as well as a right PICC lead
that ends in the upper right atrium and retained epicardial
leads. Previous mild pulmonary edema has improved, but there is
still substantial consolidation at the right lung base probably
largely atelectasis. There is no appreciable pleural effusion in
the imaged portion of the chest. The apices of the lungs are not
included in this image. Mild-to-moderate cardiomegaly is
unchanged.

EEG Study Date of [**2119-11-11**]
IMPRESSION: This continuous monitoring continues to show a
diffuse
encephalopathy that does not have any clear focal or
lateralizing
features. There were a few interictal epileptic discharges
identified
by computer algorithm but no sustained seizures.

BRONCHIAL WASHINGS Procedure Date of [**2119-11-7**]
NEGATIVE FOR MALIGNANT CELLS
Abundant hemosiderin-laden macrophages and squamous cells.

Brief Hospital Course:
76 M w Hx of systolic congestive heart failure (EF 50% in
[**2119-8-26**]), CAD s/p CABG (SVG-LAD, SVG-OM1), PCI with LCx,
mitral valve repair in [**2115**] (28 [**Doctor Last Name **] physio ring),
biventricular ICD implantantation, and atrial fibrillation s/p
AV-nodal ablation in [**2114**] (on Coumadin, INR 10.1 on
presentation), who presented with worsening shortness of breath
x 1-days duration found to have diffuse alveolar hemorrhage
resulting in acute hypoxic respiratory failure, acute on chronic
renal insufficiency, coagulopathy and anemia with
thrombocytopenia, which all fortunately resolved.
.
# ACUTE HYPOXIC RESPIRATORY FAILURE, DIFFUSE ALVEOLAR HEMORRHAGE
?????? The patient presented with a known restrictive lung disease
pattern based on previous PFTs; history of remote COPD and
extensive prior smoking history with asbestos exposures. He also
is on 2-3L home oxygen via nasal cannula at baseline. On
admission, he was acutely hypoxic with labored breathing and
tachypnea, thus he was switched from his home nasal cannula to
BiPAP with partial response initially. Overnight on [**11-6**] he
continued to have worsening oxygen desaturations in the setting
of positive pressure ventilation and he began expectorating
red-blood tinged sputum with worsening ABG values (acute
respiratory acidosis in the setting of compensatory metabolic
alkalosis). He was also aggressively diuresed (with good
diuretic response) on admission with a Lasix gtt and his CXR
appeared worsened with worsening pulmonary status. Etiologies
considered: diffuse pulmonary hemorrhage (DAH) given
coagulopathy and worsening CXR findings and acute hypoxia in the
setting of adequate diuresis vs. lobar consolidation and
pneumonia with superimposed pulmonary congestion vs. worsening
diastolic heart failure with pulmonary congestion. Given his
worsening oxygenation and poor clinical response, he was
non-urgently intubated on [**2119-11-7**]. Pulmonary Medicine was
consulted and a bronchoalveolar lavage with bronchoscopy was
requested. The bronchoscopy demonstrated evidence of blood,
although the hematocrit from the sample was < 2.0%. A chest CT
was obtained that demonstrated bilateral diffuse interstitial
thickening and multifocal peribronchial opacities and moderate
right and small left new pleural effusions suggest a combination
of multifocal lung infection and edema. These CT features did
not favor pulmonary hemorrhage nonetheless. He was also noted to
spike fevers to 101F with negative culture data, but he was
covered with IV Vancomycin, Azithromycin and Ceftriaxone since
admission -- and was broadened given concern for on-going fevers
to Cefepime on [**11-9**]. This was discontinued on [**11-12**]. Overall,
his WBC remained reassuring despite fevers. We sent a number of
vasculitides laboratory studies given the concern for a primary
lung, renal and dermatologic process (see below), which
included: a negative ANCA, negative [**Doctor First Name **], negative HIV antibody,
anti-GBM, anti-histone, cyroglobulins, anti-lupus antibody, C3
and C4 levels were normal. He was conservatively supported to
reverse his coagulopathy in the setting of his presumed diffuse
alveolar hemorrhage. He received 5 mg PO Vitamin K, 4 units of
fresh frozen plasma (for an INR of 10.1 on admission, which
improved) and 2 units of packed red cells total given an HCT of
21%. He was extubated [**11-18**]. His respiratory status returned
near his baseline of 2LNC at rest and 4LNC with exertion.
.
# DIASTOLIC CONGESTIVE HEART FAILURE ?????? The patient presented
with a known CHF history; 2D-Echo from [**8-/2119**] showing a
moderately dilated left ventricular cavity with mildly depressed
LV systolic function and mid- and apical septal hypokinesis with
inferior akinesis/hypokinesis (LVEF 34-50%, discrepancy with
perfusion imaging and 2D-Echo). Per his VNA, he has been more
edematous with increasing dyspnea, oxygen saturations in the 87%
range on 3L NC, and his wife notes that he had been coughing up
dark-red sputum, but he has remained afebrile. Although his
clinical picture became more concerning for a primary pulmonary
process, etiologies to consider for acute diastolic CHF
exacerbation: infectious (WBC 7.2, afebrile. U/A negative, urine
and blood cultures drawn and CXR showing pulmonary congestion
without focal consolidation on admission (but CT imaging later
showing multifocal consolidation and edema), lower extremity
venous stasis changed noted) vs. dietary indiscretion vs.
medication non-compliance vs. uncontrolled hypertension
(unlikely) vs. worsening valvular disease (s/p MVR repair with
2+ MR noted on 2D-Echo from [**2119-8-26**]) vs. ACS/MI (EKG
stable, Troponin 0.02) vs. Bactrim interacting with his heart
failure medications vs. progression of restrictive lung disease
(PFTs showing restrictive ventilatory defect). On exam, he
appeared volume overloaded with pedal edema and inspiratory
crackle to the mid-lung fields with elevated JVP. He was placed
on a Lasix gtt and has had adequate diuretic response with
minimal oxygenation improvement on his ABGs. Therefore he
required intubation (see above). We decreased his diuresis goal
to even or 0.5L daily given the suspicion of a primary pulmonary
process. We entertained the possible need for right heart
catheterization to evaluate his PCWP, filling pressures to
better understand his diastolic function in the setting of his
respiratory decompensation, but this was deferred. Hif formal
2D-Echo/TEE showed mild to moderate mitral regurgitation in
spite of a well-seated mitral annuloplasty ring with moderate
tricuspid regurgitation and moderate pulmonary arterial systolic
hypertension; LVEF 50-55%. Given these findings, we assumed his
lung issues were the primary concern for his respiratory
failure, with a component of diastolic heart failure. We
attempted to maintain his home heart failure regimen, but held
many of his medications given his diastolic dysfunction and
hypotension. We continued his Coreg at a lower dose initially.
We intermittently dosed IV Lasix for diuretic effect given his
diastolic failure. He seems to be currently euvolemic to mildly
hypervolemic.

# CORONARIES - The patient presented with 3-vessel coronary
artery disease status post-CABG in [**2091**] and a re-do in [**2099**]
(SVG-LAD, SVG-OM1), PCI with LCx proximal Cypher stent in [**2110**] ??????
stress testing with myocardial perfusion imaging [**2119-9-1**] showing
stable moderate predominantly fixed defect in the inferior,
inferolateral walls and apex with inferior wall hypokinesia and
an LVEF of 34% with no anginal symptoms on stress testing. He
presented with no chest pain this admission; EKG on admission
was without ST-changes, V-paced. Troponin 0.02 (times 2-sets) in
the setting of renal insufficiency, CK-MB 3. He was initially
continued on his home Aspirin dosing, but this was discontinued
given the concern for DAH. His statin medication was continued.
Serial EKGs were closely monitored.
.
# RHYTHM - The patient has a history of chronic atrial
fibrillation and is status-post ablation in [**2114**], with placement
of a biventricular device and ICD previously. His EKG
demonstrates a V-paced rhythm. For his atrial fibrillation, his
CHADs-2 score is 6 and Coumadin and Aspirin were utilized at
home. Given his findings of diffuse alveolar hemorrhage and
hematuria issues in the setting of coagulopathy, his
anticoagulation was initially held. His INR trended down nicely.
Given his 2 prior ischemic stroke events, we judiciously held
anticoagulation when his INR dropped below 2, but his bleeding
concerns were more of an issue at the time. His Coumadin was
resumed on [**2119-11-14**] after his INR and coagulopathy had
normalized and his diffuse alveolar hemorrhage concerns
subsided.
..
# SUPRATHERAPEUTIC INR, COAGULOPATHY, ANEMIA AND
THROMBOCYTOPENIA ?????? Patient presented on Coumadin for chronic
atrial fibrillation with a supratherapeutic INR of 10.1 given
his recent initiation of sulfa drug (Bactrim) for presumed lower
extremity cellulitis vs. chronic venous stasis changes. His INR
could also have been elevated in the setting of poor PO intake.
He had no evidence of bleeding on admission. His HCT was 28.7%
on admission guaiac positive in the ED with some mixed
blood-stool on rectal exam, but remained hemodynamically stable.
His INR was serially trended and improved following
administration of vitamin K and FFP while holding his
anticoagulation. Given the concern for diffuse alveolar
hemorrhage (see above), his anticoagulation was held, we
transfused him 2 units of packed red cells for a HCT of 21%, 4
units of fresh frozen plasma for INR reversal and dosed 5 mg of
PO Vitamin K. An active type and screen with adequate IV access
was maintained at all times. He developed significant marcocytic
anemia, thrombocytopenia to the 70s over his length of stay. A
DIC panel was overall reassuring, with some transient
hyperbilirubinemia, but negative peripheral smear. Hemolysis was
considered, but a DAT was negative. Hematology was consulted and
felt that marrow suppression was most likely, but other factors
were contributing, such as low iron utilization in the setting
of chronic renal insufficiency, vitamin B12 deficiency, and iron
deficiency anemia and active infection. He was supportively
managed and overall improved.
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY ?????? The patient presented
with a baseline creatinine of 1.8 to 2.5 based on our records;
renal insufficiency has been attributed to diabetic nephropathy
in combination with diastolic dysfunction and poor perfusion
pressures. His history of intolerance to ACEI/ARBs has been
noted. Now presented with creatinine of 3.0, hyponatremia to 132
and some hyperkalemia with evidence of volume overload on exam
during admission ?????? urine lytes demonstrate FeUrea of 38.45%
(FeNa of 1.73% but on diuretics) consistent with intra-renal or
post-renal process ?????? concern for ATN vs. intrinsic renal process
given poor forward perfusion pressures in the setting of acute
congestive heart failure exacerbation vs. intrinsic renal
process which could tie together his pulmonary hemorrhage and
renal failure (Goodpasture??????s vs. Wegeners or other medium-vessel
vasculitidies). As noted above, vasculitides studies were sent
but were all reassuring. His electrolytes were closely
monitored, his creatinine was trended and we avoided nephrotoxic
medications and renally dosed his medications. Nephrology was
consulted and agreed with overall management. His creatinine
steadily improved.
.
# LOWER EXTREMITY PURPURA, PETECHIAE; VENOUS STASIS CHANGES ?????? He
has evidence of chronic venous stasis changes of the lower
extremity; was started on Clindamycin and then Bactrim by his
PCP for presumed [**Name9 (PRE) 24093**] MRSA coverage and lower
extremity cellulitis vs. erysipelas. Exam on admission was
notable for prominent ecchymoses in many stages of evolution
with superimposed chronic venous insufficiency changes.
Dermatology was consulted given the irregular appearance and the
concern for a vasculitis. They thought the lesions could be
venous stasis changes vs. coagulopathy-induced ecchymoses vs.
capillaritis vs. a leukocytoclastic vasculitis (LCV). The most
likely etiology was coagulopathy-induced purpuric changes.
.
# HYPERTENSION ?????? At home, has been on Hydralazine, Isosorbide
mononitrate and Spironolactone. His Hydralazine was held given
concerns for vasculitis, and his aldosterone antagonist was held
given concerns for hyperkalemia initially.
.
# CONCERN FOR SEIZURE ACTIVITY - The patient presented with no
history of seizure activity or epilepsy, but was noted to have a
single episode of some mild, myoclonic jerking motions which
prompted a head CT which showed a stable prior ischemic infarct
in the left posterior temporal/occipital areas, unchanged from
[**2115**]. There was no new hemorrhage, infarct or mass effect. An
EEG was obtained and was without epileptiform foci or concerning
activity.
.
# HYPERLIPIDEMIA - We continued him on Simvastatin 40 mg PO
daily.
.
# GERD - We continued Ranitidine 150 mg PO daily intially, but
this was switched to Protonix 40 mg IV daily in the setting of
guiac positive stools. An H pylori antigen returned positive,
however after discussion with his PCP and gastroenterologist Dr.
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**], we decided against triple therapy as the risks of
infection outweighed the benefit of treatment.
.
# NUTRITION - On day 3 of intubation, while the patient remained
NPO, we started Isosource tube feeds for a goal rate of 45 cc/hr
given Nutrition's recommendations, which he tolerated well. Once
his delerium cleared, he passed speech and swallow video study
on [**2118-11-28**], and was advanced to a dysphagia diet.
.
TRANSITION OF CARE ISSUES:
1. Heparin bridge to coumadin (goal INR [**12-29**]) for a fib with RVR
(per his cardiologist Dr. [**Last Name (STitle) **] [**Name (STitle) 24094**] he should be on
lifelong anticoaggulation.


Medications on Admission:
Confirmed
- Home Oxygen 2L NC at rest. 4L Nasal cannula on activity.
- insulin glargine 18 Units Subcutaneous at bedtime
- ferrous sulfate 300 mg (60 mg iron) Tablet PO DAILY
- torsemide 80 mg Tab by mouth twice a day
- Carvedilol 9.375 mg Tab by mouth twice a day
- sulfamethoxazole-trimethoprim 800 mg-160 mg Tab twice daily
(thursday last)
- Aspirin 81 mg Tab by mouth once a day
- hydralazine 25 mg Tab three times daily
- Simvastatin 40 mg Tab 1 Tablet(s) by mouth QPM
- isosorbide mononitrate ER 30 mg 24 hr Tab by mouth daily
- spironolactone 25 mg Tab 1 Tablet(s) by mouth once a day
- Docusate Sodium 100 mg Cap twice a day
- warfarin 4 mg on monday, 2mg on other days
- ranitidine 150 mg Tab 1 Tablet(s) by mouth twice a day


Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
TAB PO DAILY (Daily).
4. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) TAB PO Q6H
(every 6 hours) as needed for fever, pain.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. isosorbide mononitrate 10 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB and Wheeze.
8. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for SOB and Wheeze.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
10. insulin glargine 100 unit/mL Solution Sig: Twenty (20)
Subcutaneous at bedtime.
11. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
17. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1)  Intravenous ASDIR (AS DIRECTED): Please
bridge for 48 hours of therapeutic INR ([**12-29**]) and then stop
heparin gtt.
19. Pantoprazole 40 mg IV Q24H
20. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. Furosemide 80 mg IV BID
Hold for SBP<100
22. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: Sliding scale insulin.


Discharge Disposition:
Extended Care

Facility:
Radius [**Hospital1 392**]

Discharge Diagnosis:
Diffuse alveoloar hemorrhage
Coagulopathy
Delerium
Acute on chronic systolic congestive heart failure


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]

Completed by:[**2119-11-28**]
{'Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Mixed acid-base balance disorder,Other specified alveolar and parietoalveolar pneumonopathies,Acquired coagulation factor deficiency,Other primary cardiomyopathies,Other hemoptysis,Cellulitis and abscess of leg, except foot,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage III (moderate),Other secondary thrombocytopenia,Aortocoronary bypass status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Venous (peripheral) insufficiency, unspecified,Other dependence on machines, supplemental oxygen,Spontaneous ecchymoses,Other chronic pulmonary heart diseases,Gross hematuria,Other specified cardiac device in situ,Sulfonamides causing adverse effects in therapeutic use'}


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: shortness of breath, red-tinged sputum production

PRESENT ILLNESS: This is a 76 year-old [**First Name3 (LF) 24075**]-speaking male with h/o DM,
infarct-related cardiomyopathy, CHF (most recent EF of 50% in
[**Month (only) 359**], nadir of 20%), CAD s/p CABG x 2 ([**2091**], [**2099**]) &
biventricular ICD ([**2110**]), and chronic atrial fibrillation (on
Warfarin, INR 10.1 on presentation), severe MR s/p MVR in [**2115**],
s/p AVN ablation in [**2114**], history of CRI with intolerance to ACE
inhibitors and ARBs, history of carotid artery disease not
amenable to operation, and a recent history cellulitis and
erysipelas (finished a course of doxycycline at end of [**Month (only) **])
presents with increasing dyspnea for 1 day of worsening of SOB
consistent with prior chf exacerbations. Denies fever, chills,
nausea, vomiting, cp or back pain.
.
Of note the patient has had three recent admissions for similar
symptoms of dyspnea on exertion which improved with diuresis.
(d/c [**6-8**], [**7-18**], [**9-7**]). During his most recent admission, a CT
scan was done and demonstrated generalized additional
abnormality involving both lungs with associated areas of
ground-glass opacity, which had slightly progressed since the
prior study.  Overall, radiographically likely represented
worsening pulmonary edema, interstitial lung disease could not
be ruled out.  There were a few pulmonary nodules, have been
stable since [**2115-4-25**].  There is cardiomegaly involving the
left atrium and ventricle, pulmonary arterial hypertension as
well as cholelithiasis.  Echocardiogram from that admission
demonstrated an EF of 50% with a moderately dilated LV cavity
mildly depressed LVEF and the normal RV and normal right
ventricle aorta, minimal AS, MR, 2+ MR [**First Name (Titles) 151**] [**Last Name (Titles) **] that was
estimated as moderate.  Of note, eccentric jet of at least 2+
mitral regurgitation was seen and due to acoustic shadowing, the
severity of MR could have been underestimated per report.
Spirometry and DLCO at that time also demonstrated moderate
restrictive ventilator deficit with a severe gas exchange and no
significant response with bronchodilator testing.  Most recent
spirometry testing is stable.  FVC of 1.29, 42% predicted, FEV1
is 0.94, 47% predicted; and FEV1/FVC ratio is 73, 111%
predicted. Overall, he has a stable restrictive ventilatory
deficit, no DLCO was done.  He saw pulmonary on [**2119-10-5**], who
felt that he does not have PFTs supporting COPD and stopped his
Advair and Spiriva.  They noted thrush that is likely secondary
to the Advair and gave him a 7 day course of nystatin.  He saw
his PCP [**Last Name (NamePattern4) **] [**2119-10-16**], who started him on Clindamycin 300 mg QID
for 14 days for recurrent cellulitis, however, he was not
tolerating the abx.  He was placed on Bactrim for 10 days (last
day - [**2119-11-9**]).  He was also started on Miralax for 17 g daily
for constipation.  Today, he was seen by visiting nurse today
for INR check but was found to be in CHF exacerbation (SOB,
edematous, 02 sat 87% on 3L, crackles 1/2 up. BP 110-120. Wife
reports that he has been coughing up dark sputum, not sleeping
at baseline 2 pillows at night due to PND. No fevers).  He was
referred to the ED by Dr. [**Last Name (STitle) 1911**].
.
In the ED: intial vitals were: 97.1 70 126/79 40 74% 3L NC. Labs
were significant for BNP 6843 and trop 0.02 (baseline), Cr 3.0
(baseline of 1.8), INR 10.1 and Hct 28.7. Physical exam was
significant were crackles at the bilateral lower lung fields and
erythema of the b/l lower extremity. A chest xray demonstrated
moderate congestive heart failure.   Guaiac was negative.  DRE
was notable for mixture of bright red blood and brown stool -> ?
anal lesions.  His saturation improved with BiPAP, however, his
sats fell to the 90 and he developed retractions on trial off
BiPAP.  He was given aspirin, lasix 40 x1, sl NG x2.  Vitals on
transfer: 70 107/74 33 100% on non-rebreather.
.
On arrival to the floor, initial vitals are 70 99/42 25 100%
sat. He is accompanied by wife and son and is dyspneic on exam.
His wife and son translated.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/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 chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: s/p CABG in [**2091**] and [**2099**] (SVG-LAD, SVG-OM1)
- PERCUTANEOUS CORONARY INTERVENTIONS:  Successful Cypher
stenting of the mid-LCX [**2110**]
- PACING/ICD:  biventricular ICD implantation in [**2110**]
.
3. OTHER PAST MEDICAL HISTORY:
- Chronic atrial fibrillation status post AV nodal ablation in
[**2114**]
- Chronic renal insufficiency with intolerance to ACE inhibitors
and ARBs (baseline creatinine prior to admit 1.8)
- mitral valve annuloplasty in in [**2115**] (size 28 [**Doctor Last Name **] Physio
ring)
- Diabetes type 2, on insulin
- infarcted cardiomyopathy
- CVA in [**2115**]

MEDICATION ON ADMISSION: Confirmed
- Home Oxygen 2L NC at rest. 4L Nasal cannula on activity.
- insulin glargine 18 Units Subcutaneous at bedtime
- ferrous sulfate 300 mg (60 mg iron) Tablet PO DAILY
- torsemide 80 mg Tab by mouth twice a day
- Carvedilol 9.375 mg Tab by mouth twice a day
- sulfamethoxazole-trimethoprim 800 mg-160 mg Tab twice daily
(thursday last)
- Aspirin 81 mg Tab by mouth once a day
- hydralazine 25 mg Tab three times daily
- Simvastatin 40 mg Tab 1 Tablet(s) by mouth QPM
- isosorbide mononitrate ER 30 mg 24 hr Tab by mouth daily
- spironolactone 25 mg Tab 1 Tablet(s) by mouth once a day
- Docusate Sodium 100 mg Cap twice a day
- warfarin 4 mg on monday, 2mg on other days
- ranitidine 150 mg Tab 1 Tablet(s) by mouth twice a day

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: PHYSICAL EXAMINATION (on admission):
.
VS: T=98 BP=99/42 HR=70 RR=20 O2 sat= 100% on nrb
GENERAL: Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple, JVP to 10cm.
CARDIAC: RR, normal S1, S2. [**1-30**] harsh blowing murmur heard best
at the apex but radiating to the carotids.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were labored, accessory muscle use. Stable lung exam, trace
crackles just on the left side, good air movement despite lower
saturations.
ABDOMEN: Soft, NTND. No HSM or tenderness, BS present
EXTR: 3+ edema to the ankle, erythematous, + peteche. No joint
tenderness.
SKIN: LE erythema c/w venous stasis changes.
PULSES:
Right: Carotid 2+ 1+ DP 1+ PT 2+ radial 2+
Left: Carotid 2+ DP 1+ PT 1+ radial 2+

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Married with two sons. [**Name (NI) **] is retired from construction work.
- He came from [**Country 5881**] >30 yrs ago and only speaks [**Country 24075**] but wife
can communicate well in both [**Name (NI) 24075**] and English.
- Former smoker (smoked 4ppd, quit 12 years ago) for ~120pack-yr
history
- Occasional EtOH.
- Denies other drugs.
- employment: exposure to asbestos in [**Name (NI) 24075**] navy, 41 years in
construction. 

### Response:
{'Acute respiratory failure,Acute on chronic combined systolic and diastolic heart failure,Acute kidney failure, unspecified,Mixed acid-base balance disorder,Other specified alveolar and parietoalveolar pneumonopathies,Acquired coagulation factor deficiency,Other primary cardiomyopathies,Other hemoptysis,Cellulitis and abscess of leg, except foot,Delirium due to conditions classified elsewhere,Chronic kidney disease, Stage III (moderate),Other secondary thrombocytopenia,Aortocoronary bypass status,Atrial fibrillation,Long-term (current) use of anticoagulants,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of tobacco use,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Venous (peripheral) insufficiency, unspecified,Other dependence on machines, supplemental oxygen,Spontaneous ecchymoses,Other chronic pulmonary heart diseases,Gross hematuria,Other specified cardiac device in situ,Sulfonamides causing adverse effects in therapeutic use'}
