CHIEF COMPLAINT: Bradycardia

PRESENT ILLNESS: Mr. [**Known lastname **] is a 61yo male with a past medical history significant
for CAD s/p CABG in [**2102**], HIV, hepatitis B and C, who presented
to the ED with bradycardia to the 30s. The patient reports that
he was in his baseline state of health until about 24 hours
prior to admission, when he began to feel SOB. He also reports
that he had chest pressure for about the day prior to admission,
which was relieved with administration of oxygen in the
ambulance. The patient reports taht he has been eating a lot of
potatoe chips lately. He denies use of heroin and cocaine since
mid-[**Month (only) 359**]. Notably, the patient is somnolent and it is
difficult to obtain a throrough history although he does answer
questions appropriately. He denies cough, fevers, [**Month (only) 28877**], sore
throat, rhinorrhea, headache, ear pain, sick contacts. [**Name (NI) **] says
that he is able to walk down his hallway and is not able to walk
up stairs, limited by shortness of breath. He denies orthopnea.
He denies recent travel, no hiking and no tick bites.

MEDICAL HISTORY: - Diabetes mellitus
- Dyslipidemia
- Hypertension
- Coronary artery disease s/p CABG [**2102**] with LIMA to LAD, SVG to
OM, s/p RCA stent in [**6-/2099**], re-stented in [**2-/2100**], positive
stress test in [**5-/2102**]
- CHF, LVEF 40-45% in [**2109**]
- HIV infection diagnosed in [**2084**]
- Hepatitis C, Genotype 2, not treated. Last liver biopsy in
[**2103**] showed mild portal and periportal lobular inflammation
grade 1 along with increased portal fibrosis with focal septal
and bridging fibrosis.
- Hepatitis B HBsAg-, HBsAb+, HBcAb+
- TB s/p treatment
- Anemia of chronic disease
- PVD
- History of R ocular stroke
- Status post left arm surgery for necrotizing fasciitis.
- Status post left hip surgery for abscess.
- Status post VATS [**11-1**] for pleural biopsy due to bloody
pleural effusion - cytology (-) for malignancy; c/b wound
dehiscence
-  Renal insufficiency. Cr 1.2-1.5
-  Hypokalemia.
-  Erectile dysfunction.
-  Lipodystrophy.
-  Nephropathy and neuropathy, secondary to diabetes.
-  Thyroid nodules.

MEDICATION ON ADMISSION: AMITRIPTYLINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime as needed for neuropathy pain
DARUNAVIR [PREZISTA] - 400 mg Tablet - 2 Tablet(s) by mouth
daily
Take with ritonavir. This is in place of Atazanavir and Kaletra
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
FELODIPINE - 2.5 mg Tablet Extended Release 24 hr - 1 Tablet(s)
by mouth daily
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Once daily
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
RITONAVIR [NORVIR] - 100 mg Tablet - 1 Tablet(s) by mouth daily
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
-
No Substitution
TORSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth Daily
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 40 units SQ QAM, 30 units QPM

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Azithromycin / Dapsone /
Spironolactone / tenofovir

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T=95.7 BP=47 HR=103/40 RR=14O2 sat=  100% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry mucous
membranes. No xanthalesma.
NECK: Supple with JVP of at jaw line.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardia, normal S1, S2. diastolic murmer best
appreciated at LUSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
no wheezes
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. Large area of scarring, well
healed on L entire left forearm including elbow.  Large well
healed scar on left hip. Bilateral lower extremity edema [**2-27**]+.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother died of heart disease at 32, had scarlet fever. History
of depression and alcoholism. Father died at 66 of an intestinal

SOCIAL HISTORY: Mr. [**Known lastname **] is a 35 pack years smoker, stopped smoking in [**2100**]
restarted in [**3-3**]. History of alcoholism - sober since [**2100**]. No
Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Poisoning by heroin,Other specified cardiac dysrhythmias,Pneumonia, organism unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Paralytic ileus,Other ascites,Hyposmolality and/or hyponatremia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Opioid abuse, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Impotence of organic origin,Thrombocytopenia, unspecified,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Hypotension, unspecified,Tricuspid valve disorders, specified as nonrheumatic,Aortocoronary bypass status,Long-term (current) use of insulin,Personal history of tuberculosis,Personal history of alcoholism,Accidental poisoning by heroin,Personal history of noncompliance with medical treatment, presenting hazards to health
Ac kidny fail, tubr necr,Ac on chr diast hrt fail,Poisoning-heroin,Cardiac dysrhythmias NEC,Pneumonia, organism NOS,Asymp hiv infectn status,Paralytic ileus,Ascites NEC,Hyposmolality,Hpt B chrn wo cm wo dlta,Opioid abuse-unspec,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,DMII neuro nt st uncntrl,Impotence, organic orign,Thrombocytopenia NOS,Anemia-other chronic dis,Hyperlipidemia NEC/NOS,Neuropathy in diabetes,Hypotension NOS,Nonrheum tricusp val dis,Aortocoronary bypass,Long-term use of insulin,Prsnl hst tuberculosis,Hx of alcoholism,Acc poison-heroin,Hx of past noncompliance
Admission Date:  [**2110-12-25**]              Discharge Date:   [**2111-1-8**]

Date of Birth:  [**2049-4-13**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Azithromycin / Dapsone /
Spironolactone / tenofovir

Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Bradycardia

Major Surgical or Invasive Procedure:
right internal jugular line placement
right tunneled line placement

History of Present Illness:
Mr. [**Known lastname **] is a 61yo male with a past medical history significant
for CAD s/p CABG in [**2102**], HIV, hepatitis B and C, who presented
to the ED with bradycardia to the 30s. The patient reports that
he was in his baseline state of health until about 24 hours
prior to admission, when he began to feel SOB. He also reports
that he had chest pressure for about the day prior to admission,
which was relieved with administration of oxygen in the
ambulance. The patient reports taht he has been eating a lot of
potatoe chips lately. He denies use of heroin and cocaine since
mid-[**Month (only) 359**]. Notably, the patient is somnolent and it is
difficult to obtain a throrough history although he does answer
questions appropriately. He denies cough, fevers, [**Month (only) 28877**], sore
throat, rhinorrhea, headache, ear pain, sick contacts. [**Name (NI) **] says
that he is able to walk down his hallway and is not able to walk
up stairs, limited by shortness of breath. He denies orthopnea.
He denies recent travel, no hiking and no tick bites.

In the ED, the patient was initially bradycardic to the 30s and
initially normotensive, but his pressures then dropped to
systolic 70s. Bedside ultrasound was performed which showed no
pericardial effusion and poor ventricular squeeze. Fingerstick
was 99. The patient was given atropine 1mg without change. There
was concern for beta blocker vs calcium channel  blocker
overdose and the patient was given glucagon 5mg PO with zofran.
The patient vomited in response. A cordis was placed in the RIJ
and a dopamine drip was started which increased her HR to 50s
and SBP to 100. A CXR revealed bilateral pleural effusions,
unable to exclude pna. The patient was started on broad spectrum
abx for presumed pna. The patient did receive about 1L of NS.
Throughout the patient's time in the ED, he was mentating well.

Labs are notable for creatinine 4.2 (baseline 1.5), troponin
0.03, lactate 3 and potassium 6.1 repeat K is 4.2.

On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. He denies recent fevers, [**Name (NI) 28877**] 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:
- Diabetes mellitus
- Dyslipidemia
- Hypertension
- Coronary artery disease s/p CABG [**2102**] with LIMA to LAD, SVG to
OM, s/p RCA stent in [**6-/2099**], re-stented in [**2-/2100**], positive
stress test in [**5-/2102**]
- CHF, LVEF 40-45% in [**2109**]
- HIV infection diagnosed in [**2084**]
- Hepatitis C, Genotype 2, not treated. Last liver biopsy in
[**2103**] showed mild portal and periportal lobular inflammation
grade 1 along with increased portal fibrosis with focal septal
and bridging fibrosis.
- Hepatitis B HBsAg-, HBsAb+, HBcAb+
- TB s/p treatment
- Anemia of chronic disease
- PVD
- History of R ocular stroke
- Status post left arm surgery for necrotizing fasciitis.
- Status post left hip surgery for abscess.
- Status post VATS [**11-1**] for pleural biopsy due to bloody
pleural effusion - cytology (-) for malignancy; c/b wound
dehiscence
-  Renal insufficiency. Cr 1.2-1.5
-  Hypokalemia.
-  Erectile dysfunction.
-  Lipodystrophy.
-  Nephropathy and neuropathy, secondary to diabetes.
-  Thyroid nodules.

Social History:
Mr. [**Known lastname **] is a 35 pack years smoker, stopped smoking in [**2100**]
restarted in [**3-3**]. History of alcoholism - sober since [**2100**]. No

alcohol use since then. IVDU history: Quit IV heroin and
cocaine, relapsed in [**3-3**] and is currently using. Married to a
woman who is HIV+, has one son. [**Name (NI) 1403**] two days per week at a
desk job.

Family History:
Mother died of heart disease at 32, had scarlet fever. History
of depression and alcoholism. Father died at 66 of an intestinal

gangrene after a rupture and had diabetes, alcoholism and h/o
aneurysm. There is no history of cancer.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=95.7 BP=47 HR=103/40 RR=14O2 sat=  100% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry mucous
membranes. No xanthalesma.
NECK: Supple with JVP of at jaw line.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardia, normal S1, S2. diastolic murmer best
appreciated at LUSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
no wheezes
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. Large area of scarring, well
healed on L entire left forearm including elbow.  Large well
healed scar on left hip. Bilateral lower extremity edema [**2-27**]+.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
ADMISSION LABS:

[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] WBC-5.8# RBC-3.95* Hgb-11.9* Hct-37.4*
MCV-95 MCH-30.1 MCHC-31.9 RDW-15.4 Plt Ct-97*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Neuts-59.2 Lymphs-29.2 Monos-7.4 Eos-3.8
Baso-0.4
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] PT-12.9* PTT-35.8 INR(PT)-1.2*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Plt Ct-97*
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Glucose-83 UreaN-35* Creat-4.2*# Na-134
K-6.1* Cl-104 HCO3-22 AnGap-14
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] ALT-22 AST-39 LD(LDH)-231 CK(CPK)-97
AlkPhos-125 TotBili-1.4
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] Calcium-8.8 Phos-3.4# Mg-2.1
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] TSH-1.0

PERTINENT LABS:

[**2110-12-26**] 05:38AM [**Month/Day/Year 3143**] Lipase-12
[**2110-12-25**] 01:15AM [**Month/Day/Year 3143**] cTropnT-0.03*
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] TSH-1.0
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] RheuFac-57*
[**2110-12-25**] 05:30AM [**Month/Day/Year 3143**] ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2110-12-25**] 01:19AM [**Month/Day/Year 3143**] Lactate-3.0* K-4.2
[**2110-12-25**] 07:42PM [**Month/Day/Year 3143**] Lactate-3.3*
[**2110-12-29**] 12:05PM [**Month/Day/Year 3143**] Fibrino-297#
[**2110-12-29**] 02:00AM [**Month/Day/Year 3143**] LD(LDH)-218 TotBili-0.4
[**2110-12-29**] 02:00AM [**Month/Day/Year 3143**] Hapto-29*
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] ANCA-NEGATIVE B
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] [**Doctor First Name **]-NEGATIVE
[**2110-12-26**] 10:09AM [**Month/Day/Year 3143**] RheuFac-57*
HIT PF4 antibody negative

ECHO [**12-25**] The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 65%). The right ventricular free wall
thickness is normal. The right ventricular cavity is dilated
with borderline normal free wall function. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild to moderate
([**1-26**]+) aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. Moderate to severe [3+] tricuspid
regurgitation is seen. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2110-5-10**], the tricuspid regurgitation appears worse, and
the right ventricle is dilated.

CXR [**12-25**] Moderate-to-large loculated right pleural effusion
appears increased in size from prior exam. Moderate left pleural
effusion is unchanged. Bibasilar opacities likely represent
atelectasis or infection in the appropriate clinical setting.
Mild pulmonary edema.

CXR [**12-25**] Comparison is made with prior study performed one hour
earlier.
Right IJ catheter sheath tip is at the distal/lower right
jugular vein.
Cardiomegaly is stable. Moderate right and small-to-moderate
left pleural
effusions with adjacent bibasilar atelectases are unchanged.
Mild pulmonary edema is unchanged. Multiple surgical clips
project over the left cardiac border. Several leads and external
monitors are noted.

KUB [**12-28**] ileus

Right UE duplex US [**12-28**] No DVT.

CXR: [**1-5**]
PA and lateral views of the chest. A right internal jugular
hemodialysis catheter ends in the low SVC. Sternotomy wires and
mediastinal clips are seen. Bilateral layering pleural effusions
are unchanged. No pneumothorax. Moderate cardiomegaly is stable.
Bibasilar atelectasis. There is decreased interstitial edema and
pulmonary vascular congestion.
IMPRESSION:
1. Stable bilateral layering pleural effusions. Decreased
pulmonary edema.
2. No evidence for pneumonia or active or nonactive
tuberculosis.

DISCHARGE LABS:

[**2111-1-7**] 06:31AM [**Month/Day/Year 3143**] WBC-5.7 RBC-2.65* Hgb-8.2* Hct-25.8*
MCV-98 MCH-31.0 MCHC-31.9 RDW-17.7* Plt Ct-130*
[**2111-1-7**] 06:31AM [**Month/Day/Year 3143**] Glucose-198* UreaN-51* Creat-6.4*# Na-136
K-3.9 Cl-100 HCO3-27 AnGap-13

Brief Hospital Course:
61yo male with past medical history of CAD s/p CABG, HTN, HLD,
diabetes, HIV, hepatitis C and B who is presented with
bradycardia, bilateral pleural effusions, concern for PNA by
chest imaging and acute on chronic renal failure.

ACUTE CARE:
# BRADYCARDIA - The patient initially presented with bradycardia
in a junctional rhythm and hypotension. With dopamine, the
patient's junctional rhythm converted to sinus bradycardia.  All
home antihypertensives were discontinued, Echo showed EF of 65%
which was improved from prior.  His HR and [**Month/Day/Year **] pressure
increased with dopamine, which he was eventually weaned off. The
patient's bradycardia is of unclear etiology. The most likely
etiology is the possibility of a toxin which was in the heroin
he used 2 days prior to admission.  Bradycardia resolved
spontaneously and patient was able to be started on [**1-26**] dose
metoprolol.

# ELEVATED PULMONARY ARTERY PRESSURES, RIGHT VENTRICULAR
DYSFUNCTION ?????? Question of elevated PA pressures on echo but
Right heart cath did not show evidence of right heart failure or
pulm HTN. [**Doctor First Name **], ANCA were negative.

# ACUTE ON CHRONIC RENAL FAILURE - patient with chronic renal
insufficiency with baseline creatinine of 1.5 likely secondary
to poorly controlled hypertension and diabetes.  Ceatinine on
presentation elevated to [**8-1**] with muddy casts on urinalysis and
no evidence of active sediment.  Acute renal failure was
attributed to ATN from hypotension in the setting of poor
forward flow.  Tenofovir was also discontinued given possible
cytotoxic nephrogenic effect.  Medications were renally dosed.
Nephrology was consulted and although patient initially refused
HD, dialysis was eventually initiated due to metabolic
abnormalities and uremia.  Although urine output slowly improved
through hospital course, patient remained with marginal GFR and
gross fluid overload.  A tunneled line was placed with the plan
to continue dialysis as an outpatient.  Hepatitis B surface
Antigen was negative (core antibody positive, viral load in
[**6-/2110**] was undetectable) and chest x-ray showed no evidence of
active Tuberculosis (hx of Tb s/p treatment).

# HIV: VL in [**9-/2110**] is 61 with CD4 count of 205, repeat VL
during hospitalization was 56. Due to renal function, HAART
regimen was held at time of presentation, and he was started on
a drug holiday. Management of his HAART regimen will be
difficult given his resistance and his renal failure. Atovaquone
ppx was initiated given low CD4 count.  Patient will follow up
with outpatient physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 438**], to discuss possible
HAART regimens.

# Thrombocytopenia: baseline platelet count is 100, trended down
to 48 during hospitalization. Heparin was discontinued and
evaluation for TTP, DIC and HIT were negative.  Acute decrease
in platelet count was felt to be secondary to acute illness.
Platelet count improved spontaneously and heparin was
reinitiated.  At time of discharge, platlet count had improved
to baseline of 120s.

# Diabetes: HgA1C was 7.9% in [**2110-6-25**]. Home regimen:  70/30
40U subq qam and 30 U subq qpm.  Given new onset renal failure,
insulin dose was reduced by [**1-26**] and gradually titrated to
achieve euglycemia.  At time of discharge, patient was taking
70/30 30U qam and 20U qpm.  If patient remains hyperglycemic, he
was instructed to increase dose by 2U and call endocrinologist
at [**Last Name (un) **].

# LOOSE STOOLS ?????? While patient was on broad spectrum abx (see
below), patient was noted to have copious loose stools.  Cdiff
toxins was negative and change in bowel movements was attibuted
to antibiotic associated diarrhea.  Bowel regimen was held and
patient developed relative constipation with KUB consistent with
ileus.  Ileus was managed conservatively with uptitrated bowel
regimen, and by time of discharge, bowel movements had returned
to normal.

# (?) PNEUMONIA - On presentation, patient complained of dyspnea
with CXR consistent with pulmonary edema.  Pneumonia could not
be excluded. Given initial presentation with hypotension,
patient was empirically covered with broad spectrum antibiotics
of vanc/ zosyn.  As clinical status improved, all antibiotics
were discontinued.  Respiratory status improved with initiation
of dialysis and fluid removal.

CHRONIC CARE:
# Polysubstance abuse: admitted to recent heroine use last on
[**12-22**], denies recent cocaine use. Urine tox screen positive for
opiates.  Patient was seen by social work and counseled on drug
cessation

# CAD s/p CABG in [**2102**]. As above, there was no evidence of
ischemia per EKGs or repeat Echo.  Patient had reportedly not
been taking his aspirin at home.

# HTN: the patient has a history of hypertension but was
hypotensive during his hospital stay.  Metoprolol, felodipine,
valsartan, lisinopril, spironolactone were discontinued.  [**Year (4 digits) **]
pressure stablized with SBP 110-130s and patient was able to be
re-initiated on metoprolol XL 50mg.

# Hyperlipidemia: lipids well controlled in 6/[**2110**]. Continued
pravastatin.

# Neuropathic pain: Continue amitriptyline 10mg tablet qhs prn
pain.

# Hepatitis C: chronic, stable, untreated.  LFTs remained normal
throughout stay, INR is elevated and albumin is low.

ISSUES OF TRANSITIONS IN CARE:
CODE STATUS: full code (CONFIRMED)
COMM: [**Name (NI) 4134**] [**Name (NI) **] (wife) [**Telephone/Fax (1) 42348**]
PENDING STUDIES AT TIME OF DISCHARGE: none
ISSUES TO ADDRESS AT FOLLOW UP:
1. Acute on chronic Renal failure:
- continue outpatient hemodialysis
- monitor urine output and kidney function with goal to
discontinue HD once ATN has resolved

2. HIV:
- follow up with outpatient provider to discuss reinitiation of
HARRT
- cont atovaquone for ppx

3. Diabetes:
- uptitrate insulin to maintain euglycemia

4. HTN: goal BP < 140
- discontinue lisinopril, valsartan, spironolactone, felodipine
- reduce metoprolol to 50mg daily

Medications on Admission:
AMITRIPTYLINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime as needed for neuropathy pain
DARUNAVIR [PREZISTA] - 400 mg Tablet - 2 Tablet(s) by mouth
daily
Take with ritonavir. This is in place of Atazanavir and Kaletra
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
FELODIPINE - 2.5 mg Tablet Extended Release 24 hr - 1 Tablet(s)
by mouth daily
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Once daily
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
RITONAVIR [NORVIR] - 100 mg Tablet - 1 Tablet(s) by mouth daily
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
-
No Substitution
TORSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth Daily
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 40 units SQ QAM, 30 units QPM

The following medications are on the patient's medication list
but he is not taking them:
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth every other week
ASPIRIN - 325 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
SILDENAFIL - 25 mg Tablet - 1 Tablet(s) by mouth Daily as needed
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - one Tab sublingually
as needed for Chest pain, every five minutes for a total of
three
tabs. Call your doctor or go to the emergency room for severe
chest pain
POTASSIUM CHLORIDE -  (Dose adjustment - no new Rx) - 20 mEq
Tablet, ER Particles/Crystals - 2 Tab(s) by mouth once a day

Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO QHS PRN ()
as needed for pain.
3. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
4. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen
Sig: see below  Subcutaneous twice a day: 30 Units in the
morning; 20 Units in the evening.
Disp:*5 pens* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*

Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary Diagnosis:
acute on chronic renal failure
bradycardia
hypotension

Secondary Diagnosis:
HIV
hepatitis C
diabetes mellitus
hyperlipidemia

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

Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted to [**Hospital1 18**] for very slow heart rate and low
[**Hospital1 **] pressure. You were admitted to the ICU because you
required a medication to support your heart. Your kidneys began
to decline and you were advised to initiate dialysis. You were
not able to take your HAART medications for HIV because of your
poor renal function. You were also treated for a pneumonia. It
is unclear what caused all of these symptoms but it may be
related to your drug use. It is of the utmost importance that
you do not continue to use drugs. It is also very important that
you quit smoking cigarettes.

Unfortunately your kidney function did not recover significantly
during your hospital course to allow you to come off of
dialysis.  You had to have a catheter placed to receive dialysis
as an outpatient.  However, the kidney doctors think that your
kidney function may still improve over the upcoming months.

Please note the following changes to your medications:
STOP your HAART medications: darunavir, emtricitabine-
tenofovir, ritonavir
STOP lisinopril
STOP felodipine
STOP valsartan
STOP torsemide
STOP spironolactone
DECREASE your metoprolol succinate to 50mg daily
DECREASE your insulin to 30units in the morning and 20units in
the evening
DECREASE your aspirin to 81mg daily
START nephrocaps daily
START atovaquone daily
You may take senna and colace as needed for constipation
Only take the medications that are listed on your discharge
paperwork

Please be sure to follow up with your physicians.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please go to your initial dialysis session:
Friday, [**1-9**] at 5:15pm at [**Location (un) **] [**Location (un) **]

Department: [**Hospital3 249**]
When: MONDAY [**2111-1-12**] at 3:00 PM
With: [**First Name8 (NamePattern2) 488**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8033**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: WEDNESDAY [**2111-1-14**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2111-2-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Poisoning by heroin,Other specified cardiac dysrhythmias,Pneumonia, organism unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Paralytic ileus,Other ascites,Hyposmolality and/or hyponatremia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Opioid abuse, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Impotence of organic origin,Thrombocytopenia, unspecified,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Hypotension, unspecified,Tricuspid valve disorders, specified as nonrheumatic,Aortocoronary bypass status,Long-term (current) use of insulin,Personal history of tuberculosis,Personal history of alcoholism,Accidental poisoning by heroin,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: Bradycardia

PRESENT ILLNESS: Mr. [**Known lastname **] is a 61yo male with a past medical history significant
for CAD s/p CABG in [**2102**], HIV, hepatitis B and C, who presented
to the ED with bradycardia to the 30s. The patient reports that
he was in his baseline state of health until about 24 hours
prior to admission, when he began to feel SOB. He also reports
that he had chest pressure for about the day prior to admission,
which was relieved with administration of oxygen in the
ambulance. The patient reports taht he has been eating a lot of
potatoe chips lately. He denies use of heroin and cocaine since
mid-[**Month (only) 359**]. Notably, the patient is somnolent and it is
difficult to obtain a throrough history although he does answer
questions appropriately. He denies cough, fevers, [**Month (only) 28877**], sore
throat, rhinorrhea, headache, ear pain, sick contacts. [**Name (NI) **] says
that he is able to walk down his hallway and is not able to walk
up stairs, limited by shortness of breath. He denies orthopnea.
He denies recent travel, no hiking and no tick bites.

MEDICAL HISTORY: - Diabetes mellitus
- Dyslipidemia
- Hypertension
- Coronary artery disease s/p CABG [**2102**] with LIMA to LAD, SVG to
OM, s/p RCA stent in [**6-/2099**], re-stented in [**2-/2100**], positive
stress test in [**5-/2102**]
- CHF, LVEF 40-45% in [**2109**]
- HIV infection diagnosed in [**2084**]
- Hepatitis C, Genotype 2, not treated. Last liver biopsy in
[**2103**] showed mild portal and periportal lobular inflammation
grade 1 along with increased portal fibrosis with focal septal
and bridging fibrosis.
- Hepatitis B HBsAg-, HBsAb+, HBcAb+
- TB s/p treatment
- Anemia of chronic disease
- PVD
- History of R ocular stroke
- Status post left arm surgery for necrotizing fasciitis.
- Status post left hip surgery for abscess.
- Status post VATS [**11-1**] for pleural biopsy due to bloody
pleural effusion - cytology (-) for malignancy; c/b wound
dehiscence
-  Renal insufficiency. Cr 1.2-1.5
-  Hypokalemia.
-  Erectile dysfunction.
-  Lipodystrophy.
-  Nephropathy and neuropathy, secondary to diabetes.
-  Thyroid nodules.

MEDICATION ON ADMISSION: AMITRIPTYLINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth at
bedtime as needed for neuropathy pain
DARUNAVIR [PREZISTA] - 400 mg Tablet - 2 Tablet(s) by mouth
daily
Take with ritonavir. This is in place of Atazanavir and Kaletra
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1
Tablet(s) by mouth daily
FELODIPINE - 2.5 mg Tablet Extended Release 24 hr - 1 Tablet(s)
by mouth daily
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth Once daily
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
RITONAVIR [NORVIR] - 100 mg Tablet - 1 Tablet(s) by mouth daily
SPIRONOLACTONE - 25 mg Tablet - 1 Tablet(s) by mouth once a day
-
No Substitution
TORSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth Daily
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
INSULIN NPH & REGULAR HUMAN [NOVOLIN 70/30] - 100 unit/mL
(70-30)
Suspension - 40 units SQ QAM, 30 units QPM

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Azithromycin / Dapsone /
Spironolactone / tenofovir

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T=95.7 BP=47 HR=103/40 RR=14O2 sat=  100% 2L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa, dry mucous
membranes. No xanthalesma.
NECK: Supple with JVP of at jaw line.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. bradycardia, normal S1, S2. diastolic murmer best
appreciated at LUSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
no wheezes
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No femoral bruits. Large area of scarring, well
healed on L entire left forearm including elbow.  Large well
healed scar on left hip. Bilateral lower extremity edema [**2-27**]+.
SKIN: No stasis dermatitis, ulcers, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother died of heart disease at 32, had scarlet fever. History
of depression and alcoholism. Father died at 66 of an intestinal

SOCIAL HISTORY: Mr. [**Known lastname **] is a 35 pack years smoker, stopped smoking in [**2100**]
restarted in [**3-3**]. History of alcoholism - sober since [**2100**]. No 

### Response:
{'Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Poisoning by heroin,Other specified cardiac dysrhythmias,Pneumonia, organism unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Paralytic ileus,Other ascites,Hyposmolality and/or hyponatremia,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Opioid abuse, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Impotence of organic origin,Thrombocytopenia, unspecified,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Hypotension, unspecified,Tricuspid valve disorders, specified as nonrheumatic,Aortocoronary bypass status,Long-term (current) use of insulin,Personal history of tuberculosis,Personal history of alcoholism,Accidental poisoning by heroin,Personal history of noncompliance with medical treatment, presenting hazards to health'}
