CHIEF COMPLAINT: LAD Perforation

PRESENT ILLNESS: 73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
 transferred from [**Hospital1 **] after LAD perforation.  The patient
had one month of intermittent left sided chest pain, right arm
pain and SOB. He underwent a persantine thallium stress test
that was abnormal showing large anteroseptal, apical, and
inferoseptal, inferoapical and anteroapical partially reversible
defects (EF 45%). He was scheduled for outpatient cath at
[**Hospital1 **] on [**1-11**] (Wednesday), but presented Monday ([**1-9**]) with
chest pain to the [**Hospital1 **] ED. He did not have any acute ECG
changes and CE were negative x1. The patient underwent cath
today that showed 100% occulsion of the LAD.  He received 325mg
ASA, 600mg plavix in the cath lab. A stent was deployed and
resulted in perforation of the mid LAD.  The stent balloon was
inflated in LAD and was transferred for coated stent placment.
The bivalirudin was turned off after his perforation.  He
remained hemodynamically stable with BP 160/70, sinus 70s, sat
92-96% 2L NC.
.
On arrive here to the cath lab the balloon was deflated.  There
was severe dissection of mid LAD after the first diag and just
proximal to mid LAD stent with reduced flow in the mid LAD stent
and a possible dissection distal to the stent edge with a
significant step down from the LAD stent into the LAD with
reduced outflow.  There was no evidence of continued
perforation. During the case the LAD stent thrombosed, but chest
pain improved.  The distal LAD filled with collaterals. There
was also a small pericardial effusion seen and ECHO was
performed that did not show RV collapse. A pericardiocentesis
was attempted, but no fluid was able to be drained.  The LAD
remained completely occluded and it was decided to manage him
medical overnight.
.
On arrive the patient had complaints of sharp pain across his
chest that was not similar to his anginal pain.  He rated the
pain [**2169-3-15**].  He otherwise had no other complaints.
.
On review of systems, 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. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Spiriva 18mcg one daily
Clonazapam 1mg hs
Lisinopril 5mg daily
Theophylline 200mg ER one tab [**Hospital1 **]
Nexium 40mg daily
Crestor 10mg daily
percocet prn
Combivent nebs q 4 hours during day
Symbicort 4.5 mg 2 puffs in am.
Performist inhaler 160/4.5 neb at hs
Aspirin 81 mg daily

ALLERGIES: Penicillins / Bactrim / Codeine / Prednisone / Lipitor / Vytorin
/ Tricor

PHYSICAL EXAM: T 35.4 ??????C (95.8 ??????F)
HR: 75 (67 - 75) bpm
BP: 144/79(105) {122/67(88) - 144/79(105)} mmHg
RR: 19 (14 - 19) insp/min
SpO2: 95% 4L NC
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: Mother with MI at 86

SOCIAL HISTORY: Retired, lives with his wife. Worked in construction
-Tobacco history: quit 30 yrs ago, [**2-12**] ppd x20yrs
-ETOH: occasional
-Illicit drugs: denied
Accidental puncture or laceration during a procedure, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute pericarditis, unspecified,Cardiac tamponade,Cardiac complications, not elsewhere classified,Atrial flutter,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Esophageal reflux
Accidental op laceration,Subendo infarct, initial,Acute pericarditis NOS,Cardiac tamponade,Surg compl-heart,Atrial flutter,Acc cut/hem w heart cath,Abn react-cardiac cath,Chr airway obstruct NEC,Hypertension NOS,Pure hypercholesterolem,Crnry athrscl natve vssl,Esophageal reflux
Admission Date:  [**2169-1-10**]              Discharge Date:   [**2169-1-13**]

Date of Birth:  [**2095-8-9**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Bactrim / Codeine / Prednisone / Lipitor / Vytorin
/ Tricor

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
LAD Perforation

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
 transferred from [**Hospital1 **] after LAD perforation.  The patient
had one month of intermittent left sided chest pain, right arm
pain and SOB. He underwent a persantine thallium stress test
that was abnormal showing large anteroseptal, apical, and
inferoseptal, inferoapical and anteroapical partially reversible
defects (EF 45%). He was scheduled for outpatient cath at
[**Hospital1 **] on [**1-11**] (Wednesday), but presented Monday ([**1-9**]) with
chest pain to the [**Hospital1 **] ED. He did not have any acute ECG
changes and CE were negative x1. The patient underwent cath
today that showed 100% occulsion of the LAD.  He received 325mg
ASA, 600mg plavix in the cath lab. A stent was deployed and
resulted in perforation of the mid LAD.  The stent balloon was
inflated in LAD and was transferred for coated stent placment.
The bivalirudin was turned off after his perforation.  He
remained hemodynamically stable with BP 160/70, sinus 70s, sat
92-96% 2L NC.
.
On arrive here to the cath lab the balloon was deflated.  There
was severe dissection of mid LAD after the first diag and just
proximal to mid LAD stent with reduced flow in the mid LAD stent
and a possible dissection distal to the stent edge with a
significant step down from the LAD stent into the LAD with
reduced outflow.  There was no evidence of continued
perforation. During the case the LAD stent thrombosed, but chest
pain improved.  The distal LAD filled with collaterals. There
was also a small pericardial effusion seen and ECHO was
performed that did not show RV collapse. A pericardiocentesis
was attempted, but no fluid was able to be drained.  The LAD
remained completely occluded and it was decided to manage him
medical overnight.
.
On arrive the patient had complaints of sharp pain across his
chest that was not similar to his anginal pain.  He rated the
pain [**2169-3-15**].  He otherwise had no other complaints.
.
On review of systems, 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. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

Social History:
 Retired, lives with his wife. Worked in construction
-Tobacco history: quit 30 yrs ago, [**2-12**] ppd x20yrs
-ETOH: occasional
-Illicit drugs: denied

Family History:
 Mother with MI at 86

Physical Exam:
T 35.4 ??????C (95.8 ??????F)
HR: 75 (67 - 75) bpm
BP: 144/79(105) {122/67(88) - 144/79(105)} mmHg
RR: 19 (14 - 19) insp/min
SpO2: 95% 4L NC
Heart rhythm: SR (Sinus Rhythm)

GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with flat JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTA anteriorly, no
crackles, wheezes or rhonchi.
ABDOMEN: dressing of ther epigastric region, soft, NTND. No HSM
or tenderness. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP doppler PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
[**2169-1-10**]
WBC-11.8* RBC-4.75 Hgb-14.0 Hct-41.2 Plt Ct-180
Neuts-86.8* Lymphs-7.5* Monos-3.9 Eos-1.4 Baso-0.5

PT-14.6* PTT-29.2 INR(PT)-1.3*

Glucose-119* UreaN-12 Creat-0.9 Na-141 K-4.7 Cl-108 HCO3-22
AnGap-16

ALT-20 AST-32 LD(LDH)-215 CK(CPK)-229* AlkPhos-81 Amylase-57
TotBili-0.5

[**2169-1-10**] 09:14PM CK-MB-17* MB Indx-7.4* cTropnT-0.36*
[**2169-1-11**] 04:15AM CK-MB-25* MB Indx-8.6* cTropnT-1.21*
[**2169-1-11**] 11:55AM CK-MB-18* MB Indx-7.2*

[**2169-1-13**]
WBC-7.3 RBC-4.25* Hgb-12.6* Hct-36.7*  Plt Ct-161
Glucose-96 UreaN-19 Creat-0.9 Na-143 K-3.8 Cl-107 HCO3-26
AnGap-14

ECG:
sinus rhythm at 75. normal axis. PR prolongated (234).  1mm ST
elevations in V2-V4.  T wave inversions V1-V4.

ECHO [**1-10**]:
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade but views are limited and
technically suboptimal. Right ventricular systolic function
appears globally preserved. Left ventricular systolic function
appears impaired but is not fully visualized.

ECHO [**1-11**]: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with mid to distal septal
hypokinesis/akinesis, mid to distal anterior hypokinesis and
apical akinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 45 %). Right ventricular chamber size is
normal with overall preserved free wall motion (cannot exclude
apical free wall hypokinesis). The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The left ventricular inflow pattern suggests
impaired relaxation. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade.
.
labs at discharge:
[**2169-1-13**] 06:30AM BLOOD WBC-7.3 RBC-4.25* Hgb-12.6* Hct-36.7*
MCV-86 MCH-29.7 MCHC-34.4 RDW-13.9 Plt Ct-161
[**2169-1-13**] 06:30AM BLOOD Glucose-96 UreaN-19 Creat-0.9 Na-143
K-3.8 Cl-107 HCO3-26 AnGap-14

Brief Hospital Course:
73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
 transferred from [**Hospital1 **] after LAD perforation found to have
dissection of the mid LAD, thrombosis of his stent and small
pericardial effusion.
.
# NSTEMI/LAD perforation/dissection/ pericardial effusion: Pt
with 100% occlusion of his LAD. Attempted intervention was
complicated by mid LAD dissection at OSH.  Upon transfer for
covered stent placement he subsequently thrombosed his stent. No
further attempts at PCI were made given the perforation.  Given
that pt noted that his CP is not similar to his angina, and more
consistent with pericardial irritation.  Small effusion was
noted on ECHO w/o tamponade. Pericardiocentesis was attempted,
but no fluid was removed. Pt was hemodynamically stable and CP.
Repeat ECHO was performed the following day with no worsening of
his pericardial effusion.  Cardiac enzymes were trended, with
peak CK 292 and CKMB of 25, felt to be a mild NSTEMI.  He was
monitored further with no change in his status and discharged
home.  Given the thrombosis of his LAD did not appear to be new,
with sufficient collateral development, supported by low cardiac
enzymes, no further acute intervention seemed appropriate.  CABG
was considered due to the pericardial effusion, but as the
effusion was stable, it was not pursued.

Statin was increased to Crestor 40mg. ACEI, and ASA were held
initially given concern for possible effusion/tamponade. Pt was
not on a beta blocker on admission because of his poorly
controlled COPD, this was also not started at discharge for the
same reason.  Telemetry was unremarkable.

# COPD: Pt breathing comfortably. Reports home O2 use only at
night.  He was maintained on his home medications and nebulizers
and was able to ambulate comfortably without oxygen.

# Atrial fibrillation/Atrial Flutter: Noted in CCU about 24
hours after LAD thrombosis. Pt was asymptomatic and rate
controlled with diltiazem. He spontaneously converted to NSR
within 24 hours and did not reoccur. Pt was not discharged home
on Diltiazem. Aspirin was increased to 325 mg.


Medications on Admission:
Spiriva 18mcg one daily
Clonazapam 1mg hs
Lisinopril 5mg daily
Theophylline 200mg ER one tab [**Hospital1 **]
Nexium 40mg daily
Crestor 10mg daily
percocet prn
Combivent nebs q 4 hours during day
Symbicort 4.5 mg 2 puffs in am.
Performist inhaler 160/4.5 neb at hs
Aspirin 81 mg daily


Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation once a day.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Theophylline 200 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Perforomist 20 mcg/2 mL Solution for Nebulization Sig: One
(1) vial Inhalation at bedtime.
10. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total of 3 doses: Call 911 if you
still have chest pain after 3 doses of nitroglycerin. .
Disp:*25 tabllets* Refills:*2*
12. Outpatient Lab Work
Please check Chem 7 on Monday [**1-16**] and call results to Dr.
[**Last Name (STitle) 1295**] at [**Telephone/Fax (1) 6256**]
13. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.


Discharge Disposition:
Home

Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Hypertension
Chronic obstructive Pulmonary Disease
Coronary Artery Disease
Atrial Fibrillation


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You had a cardiac catheterization at [**Hospital6 **]
and a stent placed that perforated the left anterior artery. You
were transferred here and we were not able to open the artery.
You are getting blood flow through smaller collateral arteries
and have been stable. You also had some atrial
fibrillation/atrial flutter which is an irregular heart rhythm.
This is now gone but may come back in the future.
.
Medication changes:
1. Stop taking Advil, take Tylenol instead.
2. Increase your aspirin to 325 mg
3. Increase your Crestor to 40 mg daily
4. Take nitroglycerin for chest pain


Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) 401**] [**Last Name (NamePattern1) 1295**], MD Phone: [**Telephone/Fax (1) 6256**] Please keep your appt on
[**2169-1-19**].
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] N Phone: [**Telephone/Fax (1) 8036**] Date/time: Please keep any
previously scheduled appts.



Completed by:[**2169-1-13**]
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute pericarditis, unspecified,Cardiac tamponade,Cardiac complications, not elsewhere classified,Atrial flutter,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Esophageal reflux'}


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: LAD Perforation

PRESENT ILLNESS: 73 yr old male w/ COPD, HTN, Hypercholesterolemia, h/o silent [**Hospital **]
 transferred from [**Hospital1 **] after LAD perforation.  The patient
had one month of intermittent left sided chest pain, right arm
pain and SOB. He underwent a persantine thallium stress test
that was abnormal showing large anteroseptal, apical, and
inferoseptal, inferoapical and anteroapical partially reversible
defects (EF 45%). He was scheduled for outpatient cath at
[**Hospital1 **] on [**1-11**] (Wednesday), but presented Monday ([**1-9**]) with
chest pain to the [**Hospital1 **] ED. He did not have any acute ECG
changes and CE were negative x1. The patient underwent cath
today that showed 100% occulsion of the LAD.  He received 325mg
ASA, 600mg plavix in the cath lab. A stent was deployed and
resulted in perforation of the mid LAD.  The stent balloon was
inflated in LAD and was transferred for coated stent placment.
The bivalirudin was turned off after his perforation.  He
remained hemodynamically stable with BP 160/70, sinus 70s, sat
92-96% 2L NC.
.
On arrive here to the cath lab the balloon was deflated.  There
was severe dissection of mid LAD after the first diag and just
proximal to mid LAD stent with reduced flow in the mid LAD stent
and a possible dissection distal to the stent edge with a
significant step down from the LAD stent into the LAD with
reduced outflow.  There was no evidence of continued
perforation. During the case the LAD stent thrombosed, but chest
pain improved.  The distal LAD filled with collaterals. There
was also a small pericardial effusion seen and ECHO was
performed that did not show RV collapse. A pericardiocentesis
was attempted, but no fluid was able to be drained.  The LAD
remained completely occluded and it was decided to manage him
medical overnight.
.
On arrive the patient had complaints of sharp pain across his
chest that was not similar to his anginal pain.  He rated the
pain [**2169-3-15**].  He otherwise had no other complaints.
.
On review of systems, 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. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: Spiriva 18mcg one daily
Clonazapam 1mg hs
Lisinopril 5mg daily
Theophylline 200mg ER one tab [**Hospital1 **]
Nexium 40mg daily
Crestor 10mg daily
percocet prn
Combivent nebs q 4 hours during day
Symbicort 4.5 mg 2 puffs in am.
Performist inhaler 160/4.5 neb at hs
Aspirin 81 mg daily

ALLERGIES: Penicillins / Bactrim / Codeine / Prednisone / Lipitor / Vytorin
/ Tricor

PHYSICAL EXAM: T 35.4 ??????C (95.8 ??????F)
HR: 75 (67 - 75) bpm
BP: 144/79(105) {122/67(88) - 144/79(105)} mmHg
RR: 19 (14 - 19) insp/min
SpO2: 95% 4L NC
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: Mother with MI at 86

SOCIAL HISTORY: Retired, lives with his wife. Worked in construction
-Tobacco history: quit 30 yrs ago, [**2-12**] ppd x20yrs
-ETOH: occasional
-Illicit drugs: denied 

### Response:
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Subendocardial infarction, initial episode of care,Acute pericarditis, unspecified,Cardiac tamponade,Cardiac complications, not elsewhere classified,Atrial flutter,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Esophageal reflux'}
