CHIEF COMPLAINT: Transfer for evaluation for CABG versus high-risk PCI.
angina for 4-6 weeks

PRESENT ILLNESS: 74 y/o with hx. DM2 on insulin, morbid obesity (380 lbs), PVD
s/p Rt. [**Name (NI) 6024**], CRI (unclear baseline but renal consultant at
[**Hospital 1514**] Hospital felt that her baseline was likely around 1.8
but Cr. now approx 2.4 down from peak of approx 3.6), emphysema,
who presented to [**Location (un) 11248**] [**Hospital3 **] on [**3-10**]
complaining of [**5-1**] weeks of exertional chest pain. She was found
to have bilateral DVT's and bilateral pulmonary emboli at that
time. She was heparinized. Her Troponin T was 0.11 at this time,
but rose to 0.91 - she was then noted to have recurrent chest
pain and inferior ST elevations with antrolateral reciprocal
changes. She was then given integrelin in addition to the
heparin and aspirin. She was transferred to [**Hospital 1514**] Hospital for
cath.
.
Cath [**2139-3-12**]: Lt. main: clean; Lt. Circ: 40-50% stenosis near
branch of OM2; LAD: subtotal occlusion near take-off of a diag
branch; RCA (dominant) focal 95% senosis at mid-vessel. POBA
completed with "moderate success" - 40% residual.
.
She subsequently demonstrated peak CK of [**2132**], and peak Troponin
of 234.
.
She was discharged to [**Hospital3 245**] Rehab from there [**3-26**]. She
continued to have difficulty with fluid management, and with
dyspnea. On the night of [**4-2**], she had recurrent CP alleviated
with SL NTG times two, she also complained of SOB, so she was
transfered back to [**Hospital 1514**] Hospital. She was felt to be in
congestive heart failure. Warfarin was held and she was given
heparin and integrelin again to "temporize" until transfer could
be arranged to tertiary care - she was also started on IABP on
[**2139-4-11**] due to hct drop to 24 (guaiac pos, felt to be due to
GIB associated with anticoagulation), relative hypotension and
decreased urine output; amiodarone gtt was also started because
of runs of atrial fibrillation and ventricular ectopy which made
synchronization with the IABP difficult.
.
Repeat c. cath was undertaken on [**2139-4-17**]: RCA site of
intervention appeared patent with a slight dissection at the
proximal portion of where angioplasty had been completed, but
this was not flow limiting at all. There was a tight, sub-total
occlusion of the mid LAD seen. It could not be crossed with
multiple attempts and wires. Her hct. rebounded to approx. 30
with transfusion, and at the time of transfer, her GIB seemed to
have resolved. She was additionally started on Dopamine for
"renal perfusion".
.
Prior to transfer the Heparin gtt was stopped due to falling
platelets and concern for heparin-induced thrombocytopenia, and
lepirudin was started instead. Her platelets were approx 100 at
the time of transfer.
.
Cardiac review of systems is notable for absence of chest pain;
she endorses dyspnea on exertion, ankle edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA; she has the hx. of deep venous thrombosis and 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.

MEDICAL HISTORY: STEMI as above with inf and ant. HK and EF 35%
PE's bilaterally as above
Morbid Obesity
PVD s/p Rt. [**Year (4 digits) 6024**]
Emphysema
CKD
elev. chol.
HTN

MEDICATION ON ADMISSION: Heparin, integrelin, ASA 81 mg daily, Lipitor 40 mg daily,
Plavix 75 mg daily ( last dose 3/23), lantus Insulin 95 units
QHS, Lasix 60 mg IV BID, Metoprolol 25 mg [**Hospital1 **], singulaire,
protonix, Valsartan, Ambien ,albuterol, zithromax 250 mg daily,
cipro 400 mg IV daily, hydralazine 25 mg TID, humalog SS,
zaroxolyn 5 mg daily, oxycodone prn, NTG paste 2" q 6hrs

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: Blood pressure was 163/90 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 14 breaths/min.
Generally the patient was obese and in no acute distress. The
patient was oriented to person, place and time. The patient's
mood and affect were appropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple;
there was no JVD cm. The carotid waveform was normal. There was
no thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft and
diffusely tender and slightly distended. The extremities had no
pallor, cyanosis, clubbing or edema. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral- did not palpate due to IABP site
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, although she has hx. of this and resultant emphysema. There
is no history of alcohol abuse.
Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Other pulmonary embolism and infarction,Atrial fibrillation,Other emphysema,Intestinal infection due to Clostridium difficile,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Morbid obesity,Below knee amputation status,Nonspecific abnormal findings in stool contents
CHF NOS,Subendo infarct, initial,Ac kidny fail, tubr necr,Pulm embol/infarct NEC,Atrial fibrillation,Emphysema NEC,Int inf clstrdium dfcile,Chronic kidney dis NOS,Urin tract infection NOS,Crnry athrscl natve vssl,DMII wo cmp nt st uncntr,Long-term use of insulin,Morbid obesity,Status amput below knee,Abn find-stool contents
Admission Date:  [**2139-4-19**]              Discharge Date:   [**2139-5-8**]

Date of Birth:  [**2064-3-22**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Transfer for evaluation for CABG versus high-risk PCI.
angina for 4-6 weeks

Major Surgical or Invasive Procedure:
OPCABG x3  [**2139-4-29**]  (LIMA to LAD, SVG to OM to PDA)


History of Present Illness:
74 y/o with hx. DM2 on insulin, morbid obesity (380 lbs), PVD
s/p Rt. [**Name (NI) 6024**], CRI (unclear baseline but renal consultant at
[**Hospital 1514**] Hospital felt that her baseline was likely around 1.8
but Cr. now approx 2.4 down from peak of approx 3.6), emphysema,
who presented to [**Location (un) 11248**] [**Hospital3 **] on [**3-10**]
complaining of [**5-1**] weeks of exertional chest pain. She was found
to have bilateral DVT's and bilateral pulmonary emboli at that
time. She was heparinized. Her Troponin T was 0.11 at this time,
but rose to 0.91 - she was then noted to have recurrent chest
pain and inferior ST elevations with antrolateral reciprocal
changes. She was then given integrelin in addition to the
heparin and aspirin. She was transferred to [**Hospital 1514**] Hospital for
cath.
.
Cath [**2139-3-12**]: Lt. main: clean; Lt. Circ: 40-50% stenosis near
branch of OM2; LAD: subtotal occlusion near take-off of a diag
branch; RCA (dominant) focal 95% senosis at mid-vessel. POBA
completed with "moderate success" - 40% residual.
.
She subsequently demonstrated peak CK of [**2132**], and peak Troponin
of 234.
.
She was discharged to [**Hospital3 245**] Rehab from there [**3-26**]. She
continued to have difficulty with fluid management, and with
dyspnea. On the night of [**4-2**], she had recurrent CP alleviated
with SL NTG times two, she also complained of SOB, so she was
transfered back to [**Hospital 1514**] Hospital. She was felt to be in
congestive heart failure. Warfarin was held and she was given
heparin and integrelin again to "temporize" until transfer could
be arranged to tertiary care - she was also started on IABP on
[**2139-4-11**] due to hct drop to 24 (guaiac pos, felt to be due to
GIB associated with anticoagulation), relative hypotension and
decreased urine output; amiodarone gtt was also started because
of runs of atrial fibrillation and ventricular ectopy which made
synchronization with the IABP difficult.
.
Repeat c. cath was undertaken on [**2139-4-17**]: RCA site of
intervention appeared patent with a slight dissection at the
proximal portion of where angioplasty had been completed, but
this was not flow limiting at all. There was a tight, sub-total
occlusion of the mid LAD seen. It could not be crossed with
multiple attempts and wires. Her hct. rebounded to approx. 30
with transfusion, and at the time of transfer, her GIB seemed to
have resolved. She was additionally started on Dopamine for
"renal perfusion".
.
Prior to transfer the Heparin gtt was stopped due to falling
platelets and concern for heparin-induced thrombocytopenia, and
lepirudin was started instead. Her platelets were approx 100 at
the time of transfer.
.
Cardiac review of systems is notable for absence of chest pain;
she endorses dyspnea on exertion, ankle edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA; she has the hx. of deep venous thrombosis and 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.

Past Medical History:
STEMI as above with inf and ant. HK and EF 35%
PE's bilaterally as above
Morbid Obesity
PVD s/p Rt. [**Year (4 digits) 6024**]
Emphysema
CKD
elev. chol.
HTN

Social History:
Social history is significant for the absence of current tobacco
use, although she has hx. of this and resultant emphysema. There
is no history of alcohol abuse.

Family History:
There is no family history of premature coronary artery disease
or sudden death.

Physical Exam:
Blood pressure was 163/90 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 14 breaths/min.
Generally the patient was obese and in no acute distress. The
patient was oriented to person, place and time. The patient's
mood and affect were appropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple;
there was no JVD cm. The carotid waveform was normal. There was
no thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft and
diffusely tender and slightly distended. The extremities had no
pallor, cyanosis, clubbing or edema. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral- did not palpate due to IABP site
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+

283#  67"

Pertinent Results:
[**2139-5-6**] 06:30AM BLOOD WBC-8.6 RBC-3.02* Hgb-9.4* Hct-29.0*
MCV-96 MCH-31.3 MCHC-32.5 RDW-18.1* Plt Ct-331
[**2139-5-6**] 06:30AM BLOOD PT-22.6* PTT-63.3* INR(PT)-2.2*
[**2139-5-6**] 06:30AM BLOOD Plt Ct-331
[**2139-5-6**] 06:30AM BLOOD Glucose-135* UreaN-33* Creat-1.3* Na-144
K-4.2 Cl-104 HCO3-33* AnGap-11
[**2139-4-20**] 01:58AM BLOOD CK-MB-NotDone cTropnT-0.19*

Cardiology Report ECHO Study Date of [**2139-4-29**]

PATIENT/TEST INFORMATION:
Indication: Congestive heart failure. Coronary artery disease.
Hypertension. Shortness of breath. Intraoperative TEE for off
pump  CABG procedure
Height: (in) 67
Weight (lb): 282
BSA (m2): 2.34 m2
BP (mm Hg): 138/58
HR (bpm): 90
Status: Inpatient
Date/Time: [**2139-4-29**] at 12:34
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW000-0:00
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate

REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]

MEASUREMENTS:
Left Ventricle - Ejection Fraction: 30% (nl >=55%)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aorta - Arch: 2.3 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Aortic Valve - LVOT Diam: 2.1 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 240 msec

INTERPRETATION:

Findings:

LEFT ATRIUM: No spontaneous echo contrast in the body of the [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] LAA. Good
(>20 cm/s) LAA ejection velocity. No thrombus in the LAA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA.
No ASD by 2D or color Doppler.

LEFT VENTRICLE: Severe regional LV systolic dysfunction.
Severely depressed
LVEF. No resting LVOT gradient.

LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; mid inferior - normal; mid inferolateral - hypo; mid
anterolateral -
hypo; anterior apex - akinetic; inferior apex - hypo; lateral
apex - hypo;
apex - akinetic;

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Simple atheroma in ascending aorta. Normal aortic arch
diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple
atheroma in descending aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral
annular calcification. No MS. Mild (1+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally

Conclusions:
1. No spontaneous echo contrast is seen in the body of the left
atrium or left
atrial appendage. No thrombus is seen in the left atrial
appendage. No atrial
septal defect is seen by 2D or color Doppler.

2. There is severe regional left ventricular systolic
dysfunction with
hypokinesia of the mid portions of the anterior wall, anterior
septum ,
inferior septum and septal walls. The apex is akinetic. Overall
left
ventricular systolic function is severely depressed.

3. Right ventricular chamber size and free wall motion are
normal.

4.There are simple atheroma in the ascending aorta. There are
simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic
aorta.

5. The aortic valve leaflets (3) are mildly thickened. There is
no aortic
valve stenosis. No aortic regurgitation is seen.

6. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral
regurgitation is seen.

7.There is no pericardial effusion.

8. Post revascularization LV function is unchanged. Mild mitral
regurgitation
persists.

Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2139-4-29**] 16:28.

RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2139-5-7**] 5:01 PM

CHEST (PORTABLE AP)

Reason: evaluate pleural effusions

[**Hospital 93**] MEDICAL CONDITION:
75 year old woman s/p CABG
REASON FOR THIS EXAMINATION:
evaluate pleural effusions
INDICATION: Follow up pleural effusions.

FINDINGS: Single portable AP upright chest radiograph is
reviewed and compared to multiple prior chest x-rays dating back
to [**2139-4-30**]. Limited examination due to patient body habitus.
Patient is status post median sternotomy and CABG. Postoperative
cardiomediastinal contour is unchanged. Perihilar haziness,
upper lobe vascular redistribution, and moderate bilateral
pleural effusions are unchanged. Allowing for differences in
technique, the visualized lung parenchyma is unchanged.
Bibasilar opacities most likely represent atelectasis, but
consolidation, particularly medially, cannot be excluded.

IMPRESSION: Unchanged mild pulmonary edema, with moderate
bilateral pleural effusions and probable bibasilar atelectasis.
Superimposed consolidation cannot be excluded.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]














Brief Hospital Course:
75 year old woman with CAD s/p STEMI, DM2 with PVD s/p Rt. [**Last Name (NamePattern4) 6024**],
CKD, Emphysema, morbid obesity, who had STEMI [**3-4**] now s/p
transfer from OSH with sub-total LAD occlusion, ARF, on dopamine
and IABP, for further evaluation for revascularization options
(CABG vs. PCI).  The pt. was admitted to the CCU with an IABP on
low dose Dopa.  She was not a candidate for PCI and cardiac
surgery was consulted. She had transient renal failure and
eventually her creatinine recovered at 1.5.

On [**4-29**] she underwent OPCABG x3(LIMA->LAD, SVG->OM, PDA). She
tolerated the procedure well and was transferred to the CSRU in
stable condition on epinephrine, insulin and propofol drips. She
had acidosis and required continued intubation, and extubated on
POD #2. SQ heparin started for DVT prophylaxis. Gentle diuresis
continued as drips were weaned. Chest tubes and pacing wires
removed and insulin drip required further stay in the CSRU. She
had some SVT and went in and out of A fib and was started on
heparin as well as coumadin and amiodarone. She transferred to
the floor on POD #6 to begin increasing her activity level and
rehab screening. She continued to progress and was discharged to
rehab in stable condition on POD#9.

Medications on Admission:
Heparin, integrelin, ASA 81 mg daily, Lipitor 40 mg daily,
Plavix 75 mg daily ( last dose 3/23), lantus Insulin 95 units
QHS, Lasix 60 mg IV BID, Metoprolol 25 mg [**Hospital1 **], singulaire,
protonix, Valsartan, Ambien ,albuterol, zithromax 250 mg daily,
cipro 400 mg IV daily, hydralazine 25 mg TID, humalog SS,
zaroxolyn 5 mg daily, oxycodone prn, NTG paste 2" q 6hrs

Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day). Tablet(s)
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: until [**5-12**], then 400 mg daily for 7 days,
then 200 mg daily ongoing.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: last dose PM [**5-7**].
15. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
 Subcutaneous four times a day: Follow insulin SS. Check glucose
QID.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 19504**] of [**Location (un) 1514**] - [**Location (un) 1514**], NH

Discharge Diagnosis:
CAD  s/p OPCABG x3
morbid obesity
IDDM
PVD s/p right [**Location (un) 6024**]
CRI
COPD
bilat. DVTs
PE
C. diff.
STEMI
HTN
elev. chol.
SVT
A fib


Discharge Condition:
stable


Discharge Instructions:
no lotions, creams or powders on any incision
may shower over incisions and pat dry
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
no driving for one month

Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**1-27**] weeks
see Dr. [**First Name (STitle) **] in 4 weeks  [**Telephone/Fax (1) 170**]
get referral for a local cardiologist from Dr. [**Last Name (STitle) **] and be
seen in [**2-28**] weeks


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

Completed by:[**2139-5-8**]

Name:  [**Known lastname 12034**],[**Known firstname 12035**]                Unit No:   [**Numeric Identifier 12036**]

Admission Date:  [**2139-4-19**]              Discharge Date:   [**2139-5-8**]

Date of Birth:  [**2064-3-22**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 265**]
Addendum:
Pt. is on coumadin for AF and her INR on [**5-8**] is 3.6 and she
should receive 1 mg. of coumadin tonight.  She needs daily coags
until stabilized and her INR goal is 2-2.5.

Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day). Tablet(s)
2. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 1 weeks: until [**5-12**], then 400 mg daily for 7 days,
then 200 mg daily ongoing.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days: last dose PM [**5-7**].
15. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed.
16. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day.
17. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
 Subcutaneous four times a day: Follow insulin SS. Check glucose
QID.
18. Coumadin: One (1) mg PO tonight ([**5-8**]) and dose daily for an
INR goal of [**2-27**].5

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 9368**] of [**Location (un) **] - [**Location (un) **], NH

                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]

Completed by:[**2139-5-8**]
{'Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Other pulmonary embolism and infarction,Atrial fibrillation,Other emphysema,Intestinal infection due to Clostridium difficile,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Morbid obesity,Below knee amputation status,Nonspecific abnormal findings in stool contents'}


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: Transfer for evaluation for CABG versus high-risk PCI.
angina for 4-6 weeks

PRESENT ILLNESS: 74 y/o with hx. DM2 on insulin, morbid obesity (380 lbs), PVD
s/p Rt. [**Name (NI) 6024**], CRI (unclear baseline but renal consultant at
[**Hospital 1514**] Hospital felt that her baseline was likely around 1.8
but Cr. now approx 2.4 down from peak of approx 3.6), emphysema,
who presented to [**Location (un) 11248**] [**Hospital3 **] on [**3-10**]
complaining of [**5-1**] weeks of exertional chest pain. She was found
to have bilateral DVT's and bilateral pulmonary emboli at that
time. She was heparinized. Her Troponin T was 0.11 at this time,
but rose to 0.91 - she was then noted to have recurrent chest
pain and inferior ST elevations with antrolateral reciprocal
changes. She was then given integrelin in addition to the
heparin and aspirin. She was transferred to [**Hospital 1514**] Hospital for
cath.
.
Cath [**2139-3-12**]: Lt. main: clean; Lt. Circ: 40-50% stenosis near
branch of OM2; LAD: subtotal occlusion near take-off of a diag
branch; RCA (dominant) focal 95% senosis at mid-vessel. POBA
completed with "moderate success" - 40% residual.
.
She subsequently demonstrated peak CK of [**2132**], and peak Troponin
of 234.
.
She was discharged to [**Hospital3 245**] Rehab from there [**3-26**]. She
continued to have difficulty with fluid management, and with
dyspnea. On the night of [**4-2**], she had recurrent CP alleviated
with SL NTG times two, she also complained of SOB, so she was
transfered back to [**Hospital 1514**] Hospital. She was felt to be in
congestive heart failure. Warfarin was held and she was given
heparin and integrelin again to "temporize" until transfer could
be arranged to tertiary care - she was also started on IABP on
[**2139-4-11**] due to hct drop to 24 (guaiac pos, felt to be due to
GIB associated with anticoagulation), relative hypotension and
decreased urine output; amiodarone gtt was also started because
of runs of atrial fibrillation and ventricular ectopy which made
synchronization with the IABP difficult.
.
Repeat c. cath was undertaken on [**2139-4-17**]: RCA site of
intervention appeared patent with a slight dissection at the
proximal portion of where angioplasty had been completed, but
this was not flow limiting at all. There was a tight, sub-total
occlusion of the mid LAD seen. It could not be crossed with
multiple attempts and wires. Her hct. rebounded to approx. 30
with transfusion, and at the time of transfer, her GIB seemed to
have resolved. She was additionally started on Dopamine for
"renal perfusion".
.
Prior to transfer the Heparin gtt was stopped due to falling
platelets and concern for heparin-induced thrombocytopenia, and
lepirudin was started instead. Her platelets were approx 100 at
the time of transfer.
.
Cardiac review of systems is notable for absence of chest pain;
she endorses dyspnea on exertion, ankle edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA; she has the hx. of deep venous thrombosis and 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.

MEDICAL HISTORY: STEMI as above with inf and ant. HK and EF 35%
PE's bilaterally as above
Morbid Obesity
PVD s/p Rt. [**Year (4 digits) 6024**]
Emphysema
CKD
elev. chol.
HTN

MEDICATION ON ADMISSION: Heparin, integrelin, ASA 81 mg daily, Lipitor 40 mg daily,
Plavix 75 mg daily ( last dose 3/23), lantus Insulin 95 units
QHS, Lasix 60 mg IV BID, Metoprolol 25 mg [**Hospital1 **], singulaire,
protonix, Valsartan, Ambien ,albuterol, zithromax 250 mg daily,
cipro 400 mg IV daily, hydralazine 25 mg TID, humalog SS,
zaroxolyn 5 mg daily, oxycodone prn, NTG paste 2" q 6hrs

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: Blood pressure was 163/90 mm Hg while supine. Pulse was 73
beats/min and regular, respiratory rate was 14 breaths/min.
Generally the patient was obese and in no acute distress. The
patient was oriented to person, place and time. The patient's
mood and affect were appropriate.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple;
there was no JVD cm. The carotid waveform was normal. There was
no thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft and
diffusely tender and slightly distended. The extremities had no
pallor, cyanosis, clubbing or edema. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral- did not palpate due to IABP site
Left: Carotid 2+ Femoral 1+ Popliteal 1+ DP 1+ PT 1+

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use, although she has hx. of this and resultant emphysema. There
is no history of alcohol abuse. 

### Response:
{'Congestive heart failure, unspecified,Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Other pulmonary embolism and infarction,Atrial fibrillation,Other emphysema,Intestinal infection due to Clostridium difficile,Chronic kidney disease, unspecified,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Morbid obesity,Below knee amputation status,Nonspecific abnormal findings in stool contents'}
