CHIEF COMPLAINT: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname 12795**] is a 68 year-old male with CAD s/p CABG [**2169**], COPD
on home O2, prior lung cancer (s/p RUL lobectomy), VT s/p ICD,
hyperlipidemia, type II diabetes mellitus, and atrial
fibrillation who was transferred from outside hospital for
management of hypotension. Patient presented to [**Hospital3 18201**] on the afternoon of his admission on [**4-16**] with
sytolic blood pressures in the 70's. He was intubated, given
IVF, started on levophed and dopamine, given broad spectrum
antibiotics, decadron and nebulizers. He was then sent to [**Hospital1 18**]
ED for further evaluation.
.
Per the patient's wife he was recently admitted to [**Name (NI) 29710**]
[**Date range (1) 29711**] for a COPD exacerbation requiring ICU admission but he
had not needed intubation. He was discharged on a lengthy
prednisone taper. Following discharge he remained short of
breath, wheezy, and continued to have a productive cough at
home. He also developed neck pain and shoulder pain over day
prior to this presentation. On [**4-16**] he became febrile to 101.1F.
He saw his pulmonologist in clinic [**4-16**] and was prescribed
another course of antibiotics. Then, on the way home from this
appointment he was complaining of feeling worse weakness. When
patient and wife arrived at home he was too weak to even stand
up and fell to the ground exiting the car. His wife activated
911.
.
When patient arrived to [**Hospital1 18**] ED, his pressors had been tapered
to solely levophed and systolics were in the 80's. He was
started back on neosynephrine, bolused a total of 5 liters, and
started on heparin gtt given concern for pulmonary embolism. He
was also given a dose of Cefepime and Tamiflu along with
solumedrol 125mg IV x 1. He had atrial fibrillation with RVR to
the 170's and BP again dropped to 70's. At this point levophed
was weaned down. Notably ECG showed ST depressions in V1-V4
which appeared similar to prior tracings. He was seen by the
cardiology fellow who suggested amiodarone if atrial tachycardia
recurs. Patient transferred to MICU for further management.
.
Please see hospital course details below for ICU course summary.

MEDICAL HISTORY: -Type II Diabetes
-Coronary Artery Disease:  CABG done in [**2169**], LIMA to LAD, SVG
to RAMUS, SVG to RCA. Additional PCI [**2177**]: DES placed LMCA -->
LCx, required. Required AIBP at the time.
Ventricular Tachycardia: ICD placed in [**2177**] for primary
prevention ([**Company 1543**] [**Last Name (un) 24119**] DR, a 6949 right ventricular lead.
Has PPM in place)
-Lung cancer, s/p RUL lobectomy [**2172**] chemo/rads
-COPD, on home oxygen
-Gout
-Hypertension
-Hyperlipidemia
-Atrial Fibrillation

MEDICATION ON ADMISSION: ASA 325mg daily
flucinolide 250mcg 2 puffs [**Hospital1 **]
crestor 40mg daily
plavix 75mg daily
digoxin 125 mcg daily MWF
floridil 12 mcg 1 [**Hospital1 29707**] [**Hospital1 **]
lasix 40mg [**Hospital1 **]
gabapentin 100mg [**Hospital1 **]
levothyroxine 75mcg daily
lisinopril 2.5mg daily
proventil
prednisone 10mg daily
quinidine 324 mg QID
spiriva 18 mcg daily
spirinolactone 50mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: intubated, sedated
HEENT: NC/AT, PERRL, OP clear
Neck: supple, no LAD
Lungs: anterior lung fields clear to auscultation bilaterally,
no wheezes or crackles
Heart: tachycardic, s1/s2 present, no murmurs
Abd: +BS, soft, non-tender, non-distended
Ext: no lower extremity edema, warm, well perfused
Skin: right wrist erythema with raised circular lesion
.
No Discharge Exam:
Patient was pronounced dead on [**2183-5-13**] at 4:20pm.

FAMILY HISTORY: Father had CABG in 60s, died at 81, mother with fatal MI at 71.

SOCIAL HISTORY: Patient is a retired engineer, lives with wife [**Name (NI) **] in
[**Location (un) **] MA. Prior to this admission the patient was needing
more supervision as he easily gets confused and was often
disoriented. He smoked 1PPD for nearly 45 years and quit in
[**2172**]. Rare ETOH use and no prior illicit drug use.
Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Secondary malignant neoplasm of brain and spinal cord,Candidal esophagitis,Malignant neoplasm of upper lobe, bronchus or lung,Cellulitis and abscess of upper arm and forearm,Atrial flutter,Hyperosmolality and/or hypernatremia,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Thrombocytopenia, unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Old myocardial infarction,Other specified forms of chronic ischemic heart disease,Gout, unspecified,Other and unspecified hyperlipidemia,Personal history of tobacco use,Aortocoronary bypass status,Other dependence on machines, supplemental oxygen,Personal history of malignant neoplasm of bronchus and lung,Acquired absence of organ, lung,Cardiac pacemaker in situ,Long-term (current) use of steroids,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health
MRSA septicemia,Septic shock,Meth res pneu d/t Staph,Acute respiratry failure,Food/vomit pneumonitis,Ac on chr syst hrt fail,Ac kidny fail, tubr necr,Obs chr bronc w(ac) exac,Delirium d/t other cond,Sec mal neo brain/spine,Candidal esophagitis,Mal neo upper lobe lung,Cellulitis of arm,Atrial flutter,Hyperosmolality,Severe sepsis,Hy kid NOS w cr kid I-IV,Thrombocytopenia NOS,Chronic kidney dis NOS,Anemia NOS,DMII wo cmp nt st uncntr,Cholelithiasis NOS,Old myocardial infarct,Chr ischemic hrt dis NEC,Gout NOS,Hyperlipidemia NEC/NOS,History of tobacco use,Aortocoronary bypass,Depend-supplement oxygen,Hx-bronchogenic malignan,Acq absence of lung,Status cardiac pacemaker,Long-term use steroids,Hx antineoplastic chemo,Hx of irradiation
Admission Date:  [**2183-4-16**]              Discharge Date:   [**2183-5-13**]

Date of Birth:  [**2115-2-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Hypotension

Major Surgical or Invasive Procedure:
Right IJ CVL placement
Intubation
Bronchoscopy
Lung biopsy via repeat bronchoscopy

History of Present Illness:
Mr. [**Known lastname 12795**] is a 68 year-old male with CAD s/p CABG [**2169**], COPD
on home O2, prior lung cancer (s/p RUL lobectomy), VT s/p ICD,
hyperlipidemia, type II diabetes mellitus, and atrial
fibrillation who was transferred from outside hospital for
management of hypotension. Patient presented to [**Hospital3 18201**] on the afternoon of his admission on [**4-16**] with
sytolic blood pressures in the 70's. He was intubated, given
IVF, started on levophed and dopamine, given broad spectrum
antibiotics, decadron and nebulizers. He was then sent to [**Hospital1 18**]
ED for further evaluation.
.
Per the patient's wife he was recently admitted to [**Name (NI) 29710**]
[**Date range (1) 29711**] for a COPD exacerbation requiring ICU admission but he
had not needed intubation. He was discharged on a lengthy
prednisone taper. Following discharge he remained short of
breath, wheezy, and continued to have a productive cough at
home. He also developed neck pain and shoulder pain over day
prior to this presentation. On [**4-16**] he became febrile to 101.1F.
He saw his pulmonologist in clinic [**4-16**] and was prescribed
another course of antibiotics. Then, on the way home from this
appointment he was complaining of feeling worse weakness. When
patient and wife arrived at home he was too weak to even stand
up and fell to the ground exiting the car. His wife activated
911.
.
When patient arrived to [**Hospital1 18**] ED, his pressors had been tapered
to solely levophed and systolics were in the 80's. He was
started back on neosynephrine, bolused a total of 5 liters, and
started on heparin gtt given concern for pulmonary embolism. He
was also given a dose of Cefepime and Tamiflu along with
solumedrol 125mg IV x 1. He had atrial fibrillation with RVR to
the 170's and BP again dropped to 70's. At this point levophed
was weaned down. Notably ECG showed ST depressions in V1-V4
which appeared similar to prior tracings. He was seen by the
cardiology fellow who suggested amiodarone if atrial tachycardia
recurs. Patient transferred to MICU for further management.
.
Please see hospital course details below for ICU course summary.


Past Medical History:
-Type II Diabetes
-Coronary Artery Disease:  CABG done in [**2169**], LIMA to LAD, SVG
to RAMUS, SVG to RCA. Additional PCI [**2177**]: DES placed LMCA -->
LCx, required. Required AIBP at the time.
Ventricular Tachycardia: ICD placed in [**2177**] for primary
prevention ([**Company 1543**] [**Last Name (un) 24119**] DR, a 6949 right ventricular lead.
Has PPM in place)
-Lung cancer, s/p RUL lobectomy [**2172**] chemo/rads
-COPD, on home oxygen
-Gout
-Hypertension
-Hyperlipidemia
-Atrial Fibrillation



Social History:
Patient is a retired engineer, lives with wife [**Name (NI) **] in
[**Location (un) **] MA. Prior to this admission the patient was needing
more supervision as he easily gets confused and was often
disoriented. He smoked 1PPD for nearly 45 years and quit in
[**2172**]. Rare ETOH use and no prior illicit drug use.



Family History:
Father had CABG in 60s, died at 81, mother with fatal MI at 71.

Physical Exam:
ADMISSION PHYSICAL EXAM:
General: intubated, sedated
HEENT: NC/AT, PERRL, OP clear
Neck: supple, no LAD
Lungs: anterior lung fields clear to auscultation bilaterally,
no wheezes or crackles
Heart: tachycardic, s1/s2 present, no murmurs
Abd: +BS, soft, non-tender, non-distended
Ext: no lower extremity edema, warm, well perfused
Skin: right wrist erythema with raised circular lesion
.
No Discharge Exam:
Patient was pronounced dead on [**2183-5-13**] at 4:20pm.


Pertinent Results:
ADMISSIONS LABS:
.

[**2183-4-16**] 08:44PM URINE  RBC-[**7-3**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2183-4-16**] 08:44PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2183-4-16**] 08:44PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2183-4-16**] 08:44PM   PLT SMR-LOW PLT COUNT-140*
[**2183-4-16**] 08:44PM   PT-13.2 PTT-27.9 INR(PT)-1.1
[**2183-4-16**] 08:44PM   HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2183-4-16**] 08:44PM   NEUTS-92* BANDS-5 LYMPHS-0 MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2183-4-16**] 08:44PM   WBC-21.0* RBC-3.67* HGB-11.0* HCT-32.9*
MCV-90 MCH-29.9 MCHC-33.4 RDW-15.7*
[**2183-4-16**] 08:44PM   CALCIUM-7.4*
[**2183-4-16**] 08:44PM   cTropnT-0.06*
[**2183-4-16**] 08:44PM   CK-MB-5 proBNP-4087*
[**2183-4-16**] 08:44PM   ALT(SGPT)-19 AST(SGOT)-26 CK(CPK)-179 ALK
PHOS-50 TOT BILI-0.9
[**2183-4-16**] 08:51PM   GLUCOSE-167* LACTATE-1.0 NA+-130* K+-4.4
CL--95* TCO2-25
[**2183-4-16**] 08:51PM   COMMENTS-GREEN TOP
[**2183-4-16**] 10:39PM   TYPE-ART RATES-16/4 TIDAL VOL-450 O2-100
PO2-366* PCO2-56* PH-7.24* TOTAL CO2-25 BASE XS--4 AADO2-306 REQ
O2-56 INTUBATED-INTUBATED VENT-CONTROLLED
[**2183-4-16**] 11:30PM   TYPE-ART PO2-108* PCO2-52* PH-7.25* TOTAL
CO2-24 BASE XS--4
.
.
.
MICROBIOLOGY STUDIES:

[**2183-4-17**] 6:35 pm CATHETER TIP-IV      Source: Femoral line.
WOUND CULTURE (Final [**2183-4-19**]):    No significant growth
.
Blood Culture, Routine (Final [**2183-4-20**]):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.


                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S
.

[**2183-4-17**] 10:04 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2183-4-20**]**

   GRAM STAIN (Final [**2183-4-17**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2183-4-20**]):
      Commensal Respiratory Flora Absent.
      STAPH AUREUS COAG +.    SPARSE GROWTH.  OF TWO COLONIAL
MORPHOLOGIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

[**2183-4-30**] 4:51 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2183-4-30**]**

   GRAM STAIN (Final [**2183-4-30**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2183-4-30**]):
      TEST CANCELLED, PATIENT CREDITED.

.

[**2183-5-1**] 2:40 pm BRONCHOALVEOLAR LAVAGE /
     **FINAL REPORT [**2183-5-4**]**

   GRAM STAIN (Final [**2183-5-1**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2183-5-4**]):
      ~[**2173**]/ML Commensal Respiratory Flora.
.

URINE CULTURE (Final [**2183-5-1**]):    NO GROWTH.
URINE CULTURE (Final [**2183-4-25**]):    NO GROWTH.
URINE CULTURE (Final [**2183-4-21**]):    NO GROWTH.

.
Blood Culture, Routine (Final [**2183-5-7**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-5-7**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-5-6**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-5-6**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-4-30**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-4-30**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-4-25**]):    NO GROWTH.
Blood Culture, Routine (Final [**2183-4-24**]):    NO GROWTH.
==============================================

IMAGING:

TTE [**2183-4-17**]:
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe regional left ventricular systolic dysfunction with
thinned inferolateral and inferior wall akinesis/dyskinesis and
anterolateral hypokinesis. Overall left ventricular systolic
function is severely depressed (LVEF= 25 %). The right
ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. Mild to
moderate ([**1-25**]+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. No masses or vegetations are seen
on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. An eccentric, posteriorly directed jet
of Moderate (2+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild to moderate
pulmonary artery systolic hypertension. The pulmonic valve
leaflets are thickened. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a promient fat pad.

Compared with the prior study (images reviewed) of [**2181-10-17**],
the severity of mitral and aortic regurgitation has increased.
Regional left ventricular systolic function may be slightly
worse. No vegetations identified. If clinically indicated, a
transesophageal echocardiographic examination is recommended to
evaluate for endocarditis.
------
TEE [**2183-4-18**]:
No valvular or lead vegetations seen. Mild to moderate aortic
regurgitation. Moderate mitral regurgitation. Complex (>4 mm,
non-mobile) atheroma in the descending aorta and aortic arch.
Depressed biventricular systolic function.
.
[**2183-4-16**] CXR:  Markedly abnormal radiograph with no comparison
available.
Endotracheal tube is slightly high. Consider advancement by 2.5
cm for
optimal placement. There is a right upper chest thoracoplasty
which results
in significant distortion of the normal anatomy. Patchy foci of
opacity,
particularly in the lateral left lung may represent foci of
pneumonia or
aspiration.
.
[**2183-4-18**] CXR: Bibasilar atelectasis and bronchiectasis persist,
left greater
than right. Small layering left pleural effusion is unchanged.
There is no
pulmonary edema. Right upper thoracoplasty changes are noted.
Monitoring and support devices are stable in course and
position. There is no pneumothorax. Multiple calcified
gallstones are seen in the right upper quadrant.
.
[**2183-4-23**] CXR : Changes of right upper lobectomy and thoracoplasty
are present. There is persistent bibasilar atelectasis, left
greater than right. A small left pleural effusion is unchanged.
Mild cardiomegaly is stable. Mediastinal clips and median
sternotomy wires are well aligned. A right PICC terminates at
the cavoatrial junction. A left chest wall pacemaker has leads
in the right atrium and ventricle. A Dobbhoff tube courses into
the abdomen and beyond the film. There is no pneumothorax.
Calcified gallstones are again noted in the right upper
quadrant.
.
[**2183-4-29**] CXR: Changes of right upper lobectomy and thoracoplasty
are again seen. There is persistent bibasilar atelectasis, left
greater than right. No focal consolidation is appreciated.
Probable small bilateral layering effusions are present. The
cardiomediastinal and hilar contours are normal. Monitoring
support devices are unchanged in course and position. A right
PICC is indistinctly seen at the level of the clavicle. There is
no pneumothorax. Calcified gallstones are noted in the right
upper quadrant.
.
[**2183-5-6**] CXR: In comparison with the study of [**5-5**], there is
little change.
Monitoring and support devices remain in place. Continued
increased sharpness of the left hemidiaphragm, consistent with
improved aeration at the left base.Nevertheless, there are
continued low lung volumes and bibasilar atelectatic changes.

.
[**2183-5-9**] CXR: As compared to the previous radiograph, there is no
relevant
change. The minimal further improvement of ventilation in the
region of the
pre-existing retrocardiac and left basal opacity. Otherwise,
unchanged
appearance of the lung parenchyma, the cardiac silhouette and
the chest wall.
.
[**2183-5-12**] CXR: Pulmonary edema previously, it is gone now.
Multiple foci of
atelectasis in the left lung are stable. Heart is borderline
enlarged.
New feeding tube with the wire stylet in place ends in the
stomach.
Gallstones noted in the right upper quadrant. Transvenous right
atrial pacer and right ventricular pacer leads follow their
expected courses. No
pneumothorax. Small left pleural effusion or pleural thickening
is
longstanding.
.
[**2183-5-6**] LUNG PATHOLOGY FROM FNA / BIOPSY WITH BRONCHOSCOPY LUL :
Lung (left upper lobe), fine needle aspirate:
 POSITIVE FOR MALIGNANT CELLS, consistent with squamous cell
carcinoma.
.
[**4-17**] ADMISSION CT IMAGING: CHEST/ABD/PELVIS REPORT

CT OF THE CHEST WITHOUT CONTRAST: There is a small left-sided
pleural
effusion. The patient is status post right upper and right
middle
lobectomies. There is a small right-sided pleural effusion and
small areas of loculated fluid near the apex. There is bibasilar
atelectasis. Right chest wall deformity is present from prior
thoracotomy.
There are prominent coronary artery calcifications. A small
linear area of
fat density is noted along the left ventricle, consistent with
fatty
deposition. The patient has a pacemaker with leads in right
atrium and ventricle. There is a left subclavian stent. The
endotracheal tube ends approximately 4.0 cm above the carina.
Patient is status post sternotomy and CABG.

CT OF THE ABDOMEN WITHOUT CONTRAST: The non-contrast appearance
of the
spleen, adrenal glands, stomach, and intra-abdominal loops of
bowel are within normal limits. The liver demonstrates a small
area of pneumobilia in the left lobe of the liver. There are
multiple, calcified gallstones within the gallbladder. The
common bile duct and pancreas are within normal limits. The
kidneys are slightly small bilaterally. There are prominent
renal vascular calcifications. There is no retroperitoneal or
mesenteric lymphadenopathy. There is no free air or free fluid.
There is a small fat-containing umbilical hernia. An NG tube
ends within the stomach.
 .
CT OF THE PELVIS WITHOUT CONTRAST: The rectum, prostate, and
intrapelvic
loops of bowel are within normal limits. A Foley catheter is
noted within a
decompressed bladder. There is no free air or free fluid. There
is no pelvic or inguinal lymphadenopathy. The patient is status
post placement of right femoral venous line, which ends in the
right iliac vein just prior to the bifurcation. Areas of
stranding and small foci of air within the right groin are
likely due to recent line placement. There is dense
calcification of the abdominal and pelvic arterial vasculature.

BONE WINDOWS: No concerning osseous lesions are identified. Mild
degenerative changes are noted most prominently in the lumbar
spine.

IMPRESSION:
1. No acute intrathoracic or intraabdominal process.
2. Status post right upper and right middle lobectomies with
corresponding
chest wall deformity. Small areas of loculated fluid noted at
the right lung apex. Small left-sided pleural effusion.
3. Cholelithiasis.
.
==========================================
EKGs:
[**2183-5-10**] - rate 105, Sinus tachycardia with ventricular premature
beat versus aberrant conduction.
[**2183-5-8**] -rate 80, Atrial paced rhythm. Right bundle-branch
block. Infero-posterolateral myocardial infarction of
indeterminate age but may be old. Diffuse ST-T wave
abnormalities are non-specific but clinical correlation is
suggested.
[**2183-4-16**] - rate 108, sinus tachycardia with RBBB, evidence of
prior MI in lateral and inferoposterior distribution, similar to
EKGs from 2/[**2182**].
.
==========================================
LAST SET OF LABS [**2183-5-13**] :
[**2183-5-13**] 05:20AM BLOOD WBC-9.3 RBC-3.16* Hgb-9.8* Hct-30.7*
MCV-97 MCH-30.9 MCHC-31.8 RDW-17.8* Plt Ct-319
[**2183-5-13**] 05:20AM BLOOD Glucose-253* UreaN-41* Creat-1.7* Na-146*
K-4.4 Cl-101 HCO3-36* AnGap-13
[**2183-5-13**] 05:20AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.5
.
THYROID STUDIES:
[**2183-4-24**] 04:00AM BLOOD TSH-4.7*
.
DRUG MONITORING:
[**2183-5-11**] 04:11AM BLOOD Vanco-20.9*
[**2183-4-25**] 04:11AM BLOOD Digoxin-0.2*

Brief Hospital Course:
HYPOTENSION: Patient was transferred from OSH after presentation
for weakness and pre-syncopal episode in his driveway witnessed
by his wife. [**Name (NI) **] had notable systolic blood pressured in the 70s
in ED at OSH prior to transfer and he needed to be placed on
both levophed and neosynephrine initially. Hypotension likely
due to his later established MRSA bacteremia and sepsis. CT done
and no overt pulmonary emboli revealed to explain his marked
hypotension. He was also ruled out for acute coronary syndrome
given his prominent cardiac history and multiple risk factors.
He also had rapid atrial fibrillation on day of admission which
also contributed to poor cardiac output in setting of his
already poor cardiac function with baseline EF of 35%. During
his ICU course he was weaned down to Levophed alone and then
slowly taken off pressor support completely with gentle fluid
boluses for occasional low blood pressures which were
predominantly limited to the setting of him requiring amiodarone
boluses or IV metoprolol pushes when his atrial fibrillation
episodes occurred throughout his ICU stay. Otherwise, blood
pressures improved overall after patient had been adequately
treated with IV Vancomycin for his MRSA bacteremia and MRSA
pneumonia.

MRSA BACTEREMIA: Blood cultures from admission grew out MRSA.
Initially felt that his right hand cellulitis from recent IV
placement may have been possible source. However, a sputum
culture grew out MRSA within days of admission and his CXR had
an area of patchy opacity in the lateral left lung on admission
with was felt to  represent foci of pneumonia vs. aspiration.
During his hospital course he had immediate follow-up TTE and
TEEs which were both negative for vegetations.
He was given a prolonged course of IV Vancomycin starting on
[**4-17**] or MRSA bacteremia and MRSA pneumonia.  He was followed by
the ID consult service.
.
RESPIRATORY FAILURE: Patient intubated at OSH before transfer.
He was extubated to BIPAP and required intermittent BIPAP for
about 24 hrs following extubation. He continued to struggle with
hypoxemia and shortness of breath and required re-intubation
after additional hypercarbia developed on [**2183-4-30**]. Treated with
additional Zosyn antibiotics for concern for additional
aspiration PNA which may have triggered need for his second
intubation. He was given multiple IV Lasix PRN doses and even a
Lasix drip at times to help accomplish diuresis for his ongoing
pulmonary edema which was also another factor felt to be
contributing to his poor respiratory status. On [**2183-5-1**] had a
bronchoscopy that showed area of small collapse in LUL with
question of recurrent lung cancer so interventional pulmonology
team consulted and after holding Plavix dose for about a week he
had lung biopsy and repeat bronchoscopy which was consistent
with malignant mass and pathology revealed squamous cell lung
cancer. A formal oncology consult was deferred in setting of his
very tenuous status in ICU as team was waiting for patient to
stabilize for formal consult and possible attempts for
palliative radiation/medications but patient continued to
clinically decline in ICU. There were brief discussions for
PEG/tracheostomy placement but patient was able to be extubated
successfully [**2183-5-7**]. He slowly declined again to the point of
needing high flow face mask to maintain adequate oxygenation.
Patient and family changed code status to DNR/DNI on [**2183-5-9**] and
palliative care consult was called. Overall, patient's
persistent decline and respiratory failure felt to be
combination of his underlying poor reserve with COPD /prior
lobectomy, recent PNAs, recurrent lung cancer and pulmonary
edema which lingered as well. He was made CMO on [**2183-5-13**] and
passed away later that night.
.
COPD EXACERBATION: Initially treated more aggressively with
steroids and standing nebulizers. COPD flare up was attributed
to persistent pneumonia. As above, respiratory failure required
two intubations and multiple use of BIPAP and facemask at high
flow to maintain oxygen saturations >88%. He continued to
decline after second extubation and family and patient opted to
be DNR/DNI, then changed to CMO.
.
ICU DELIRIUM: Multifactorial and felt to be related to
infection, steroids, and  being in ICU. Patient was also noted
to have recurrent lung cancer and brain metastasis is also
possible although patient was never stable enough to pursue any
additional MRI or further workup for oncologic
staging/management. Notably, wife reported sun downing at home
and issues with confusion for several months prior to admission.
He was treated initially with olanzapine and then switched to
standing Haldol with good effect initially but he seemed to get
more agitated so QHS Zydis was combined with standing and PRN
haldol dosing. EKGs were monitored for QT changes. Psychiatry
was consulted and agreed with Haldol therapy. Unfortunately, his
delerium worsened over the last few days of his ICU course and
he required soft restraints and additional doses of Haldol with
frequent re-orientation by staff.
.
RAPID ATRIAL FIBRILLATION: Patient had known atrial fibrillation
in the past. During his ICU course he had atrial flutter and
fibrillation multiple times. Likely triggers were sepsis,
pressor use, and hypoxia. Cardiology was consulted for
additional guidance during his ICU stay. Patient's home regimen
of quinidine stopped and he was loaded with IV amiodarone given
his hemodynamic instability with rapid rhythm. Patient followed
by electrophysiology service. He was re-bolused with Amiodarone
for ongoing SVT and later in hospital course metoprolol IV was
added on a standing basis for additional control and worked
well.
.
SWALLOWING: Failed speech and swallow. Dobhoff placed for
nutritional feedings. Started on TF regimen. PEG considered
briefly but after goals of care discussion with family after
recurrent lung cancer diagnosis and worse respiratory failure
and progressive altered mental status the family wished to only
keep patient comfortable and did not want any more surgeries. He
was given Dobhoff feedings up until day he expired.
.
[**Female First Name (un) **] ESOPHAGITIS: Thrush on admission with throat pain.
Treated with 7 day course of IV fluconazole for presumed [**Female First Name (un) **]
esophagitis. Resolved with therapy.
.

Medications on Admission:
ASA 325mg daily
flucinolide 250mcg 2 puffs [**Hospital1 **]
crestor 40mg daily
plavix 75mg daily
digoxin 125 mcg daily MWF
floridil 12 mcg 1 [**Hospital1 29707**] [**Hospital1 **]
lasix 40mg [**Hospital1 **]
gabapentin 100mg [**Hospital1 **]
levothyroxine 75mcg daily
lisinopril 2.5mg daily
proventil
prednisone 10mg daily
quinidine 324 mg QID
spiriva 18 mcg daily
spirinolactone 50mg daily


Discharge Medications:
No discharge medications to list
.
Patient deceased, died on [**2183-5-13**].

Discharge Disposition:
Expired

Discharge Diagnosis:
patient deceased, passed away on [**2183-5-13**]

Discharge Condition:
patient deceased, passed away on [**2183-5-13**]

Discharge Instructions:
patient deceased, passed away on [**2183-5-13**]

Followup Instructions:
patient deceased, passed away on [**2183-5-13**]


Completed by:[**2183-5-20**]
{'Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Secondary malignant neoplasm of brain and spinal cord,Candidal esophagitis,Malignant neoplasm of upper lobe, bronchus or lung,Cellulitis and abscess of upper arm and forearm,Atrial flutter,Hyperosmolality and/or hypernatremia,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Thrombocytopenia, unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Old myocardial infarction,Other specified forms of chronic ischemic heart disease,Gout, unspecified,Other and unspecified hyperlipidemia,Personal history of tobacco use,Aortocoronary bypass status,Other dependence on machines, supplemental oxygen,Personal history of malignant neoplasm of bronchus and lung,Acquired absence of organ, lung,Cardiac pacemaker in situ,Long-term (current) use of steroids,Personal history of antineoplastic chemotherapy,Personal history of irradiation, 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: Hypotension

PRESENT ILLNESS: Mr. [**Known lastname 12795**] is a 68 year-old male with CAD s/p CABG [**2169**], COPD
on home O2, prior lung cancer (s/p RUL lobectomy), VT s/p ICD,
hyperlipidemia, type II diabetes mellitus, and atrial
fibrillation who was transferred from outside hospital for
management of hypotension. Patient presented to [**Hospital3 18201**] on the afternoon of his admission on [**4-16**] with
sytolic blood pressures in the 70's. He was intubated, given
IVF, started on levophed and dopamine, given broad spectrum
antibiotics, decadron and nebulizers. He was then sent to [**Hospital1 18**]
ED for further evaluation.
.
Per the patient's wife he was recently admitted to [**Name (NI) 29710**]
[**Date range (1) 29711**] for a COPD exacerbation requiring ICU admission but he
had not needed intubation. He was discharged on a lengthy
prednisone taper. Following discharge he remained short of
breath, wheezy, and continued to have a productive cough at
home. He also developed neck pain and shoulder pain over day
prior to this presentation. On [**4-16**] he became febrile to 101.1F.
He saw his pulmonologist in clinic [**4-16**] and was prescribed
another course of antibiotics. Then, on the way home from this
appointment he was complaining of feeling worse weakness. When
patient and wife arrived at home he was too weak to even stand
up and fell to the ground exiting the car. His wife activated
911.
.
When patient arrived to [**Hospital1 18**] ED, his pressors had been tapered
to solely levophed and systolics were in the 80's. He was
started back on neosynephrine, bolused a total of 5 liters, and
started on heparin gtt given concern for pulmonary embolism. He
was also given a dose of Cefepime and Tamiflu along with
solumedrol 125mg IV x 1. He had atrial fibrillation with RVR to
the 170's and BP again dropped to 70's. At this point levophed
was weaned down. Notably ECG showed ST depressions in V1-V4
which appeared similar to prior tracings. He was seen by the
cardiology fellow who suggested amiodarone if atrial tachycardia
recurs. Patient transferred to MICU for further management.
.
Please see hospital course details below for ICU course summary.

MEDICAL HISTORY: -Type II Diabetes
-Coronary Artery Disease:  CABG done in [**2169**], LIMA to LAD, SVG
to RAMUS, SVG to RCA. Additional PCI [**2177**]: DES placed LMCA -->
LCx, required. Required AIBP at the time.
Ventricular Tachycardia: ICD placed in [**2177**] for primary
prevention ([**Company 1543**] [**Last Name (un) 24119**] DR, a 6949 right ventricular lead.
Has PPM in place)
-Lung cancer, s/p RUL lobectomy [**2172**] chemo/rads
-COPD, on home oxygen
-Gout
-Hypertension
-Hyperlipidemia
-Atrial Fibrillation

MEDICATION ON ADMISSION: ASA 325mg daily
flucinolide 250mcg 2 puffs [**Hospital1 **]
crestor 40mg daily
plavix 75mg daily
digoxin 125 mcg daily MWF
floridil 12 mcg 1 [**Hospital1 29707**] [**Hospital1 **]
lasix 40mg [**Hospital1 **]
gabapentin 100mg [**Hospital1 **]
levothyroxine 75mcg daily
lisinopril 2.5mg daily
proventil
prednisone 10mg daily
quinidine 324 mg QID
spiriva 18 mcg daily
spirinolactone 50mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
General: intubated, sedated
HEENT: NC/AT, PERRL, OP clear
Neck: supple, no LAD
Lungs: anterior lung fields clear to auscultation bilaterally,
no wheezes or crackles
Heart: tachycardic, s1/s2 present, no murmurs
Abd: +BS, soft, non-tender, non-distended
Ext: no lower extremity edema, warm, well perfused
Skin: right wrist erythema with raised circular lesion
.
No Discharge Exam:
Patient was pronounced dead on [**2183-5-13**] at 4:20pm.

FAMILY HISTORY: Father had CABG in 60s, died at 81, mother with fatal MI at 71.

SOCIAL HISTORY: Patient is a retired engineer, lives with wife [**Name (NI) **] in
[**Location (un) **] MA. Prior to this admission the patient was needing
more supervision as he easily gets confused and was often
disoriented. He smoked 1PPD for nearly 45 years and quit in
[**2172**]. Rare ETOH use and no prior illicit drug use. 

### Response:
{'Methicillin resistant Staphylococcus aureus septicemia,Septic shock,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Obstructive chronic bronchitis with (acute) exacerbation,Delirium due to conditions classified elsewhere,Secondary malignant neoplasm of brain and spinal cord,Candidal esophagitis,Malignant neoplasm of upper lobe, bronchus or lung,Cellulitis and abscess of upper arm and forearm,Atrial flutter,Hyperosmolality and/or hypernatremia,Severe sepsis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Thrombocytopenia, unspecified,Chronic kidney disease, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Calculus of gallbladder without mention of cholecystitis, without mention of obstruction,Old myocardial infarction,Other specified forms of chronic ischemic heart disease,Gout, unspecified,Other and unspecified hyperlipidemia,Personal history of tobacco use,Aortocoronary bypass status,Other dependence on machines, supplemental oxygen,Personal history of malignant neoplasm of bronchus and lung,Acquired absence of organ, lung,Cardiac pacemaker in situ,Long-term (current) use of steroids,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health'}
