CHIEF COMPLAINT: hypotension s/p cardiac cath

PRESENT ILLNESS: 77 year old male with h/o HTN, EF 45%, hyperlipidemia, PVD, CVA,
s/p right CEA, STEMI (ST depressions in V2-V6 and 1mm STE in
III, 0.5mm STE in II and avF; [**5-7**]), 3vCAD s/p CAGB x1 (Dr.
[**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU
monitoring after cardiac cath with stent placement. The patient
has been symptomatic again with his typical exertional chest
pain for the last few weeks (responsive to Nitro). He was
recently ruled out for an MI during an admission from
[**Date range (1) 16589**] (also found to have ARF which resolved after IVF).
He was scheduled for an outpatient stress test on [**2149-4-3**]. The
exercise stress test was positive (6.75 minutes [**Doctor Last Name 4001**]
protocol, 66% max PHR, stopping due progressive anginal symptoms
with 9/10 arm pain radiating to the chest). The MIBI showed a
reversible defect in the lateral wall and he was sent for
cardiac cath on the day of admission.
.
A cypher stent was placed into LM/LAD. It was attempted to place
also a stent into the mid-distal LAD lesion but failed. During
the catheterization, he developed intermittent CP. His SBP went
up into the 220s and he received IV nitro. Next, the question of
a dissected LAD came up based on the angiographic image of the
wire. He received intracoronary Nitro (200 mcg) to dilate the
vessel and identify any dissection which could not be confirmed.
After this administration, his SBP dropped into the 70s and he
developed a vagal reaction with HR in upper 30s to lower 40s.
This event lasted approx 5 minutes and he responded to IV
atropin, very brief dopamine drip and IVF. There was no LOC but
some associated CP. There were transient ischemic changes during
the procedure (ST depressions in V4-V6). He was exposed to more
than 350cc of dye, about one hour of fluoro and he lost a
significant amount of blood. He received Angiomax in the cath
lab and was started on a bicarb drip. He next was transferred to
the CCU for monitoring after the above mentioned events.

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Systolic CHF (EF 45%; [**5-7**])
[**5-7**]: STEMI; 3vCAD with subsequent CABG x 1
[**2138**] CVA
Carotid artery disease, s/p right CEA in [**2144**]
PVD (known bruit over right groin) with claudication
Gout
GERD
Lower back pain s/p L4-5 laminectomy
Nasal fractures, s/p surgical correction
Tonsillectomy

MEDICATION ON ADMISSION: Aspirin 325mg daily every morning
Plavix 75mg daily every morning
Metoprolol 50mg twice a day
Zocor 40mg daily every evening
Prilosec 20mg every morning
Norvasc 5mg daily every morning

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T BP 167/59 HR 59 RR 18 O2 100% RA
Gen: WDWN 77 year old male in NAD. Alert & Oriented. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very dry MM.
Neck: Supple without elevated JVP. Right carotic bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Soft, I/VI systolic murmur at apex, no rub or
gallop. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Cold feet b/l (chronic per patient). No femoral
bruits (but reportedly known right groin bruit pre-procedure -
not audible currently with gauze/tape covering groin).
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: Brother with ??????heart problems??????, died in his 40??????s.

SOCIAL HISTORY: 100-pack-year history of smoking,and discontinued in [**2136**].
Social beer drinking (about 6 beers 3x/week). Married with four
children.
Cardiac complications, not elsewhere classified,Systolic heart failure, unspecified,Other and unspecified angina pectoris,Acute kidney failure, unspecified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia
Surg compl-heart,Systolic hrt failure NOS,Angina pectoris NEC/NOS,Acute kidney failure NOS,Cardiac dysrhythmias NEC,Iatrogenc hypotnsion NEC,Crnry athrscl natve vssl,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2149-4-4**]              Discharge Date:   [**2149-4-5**]

Date of Birth:  [**2072-3-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
hypotension s/p cardiac cath

Major Surgical or Invasive Procedure:
cardiac cath plus stenting of LAD

History of Present Illness:
77 year old male with h/o HTN, EF 45%, hyperlipidemia, PVD, CVA,
s/p right CEA, STEMI (ST depressions in V2-V6 and 1mm STE in
III, 0.5mm STE in II and avF; [**5-7**]), 3vCAD s/p CAGB x1 (Dr.
[**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU
monitoring after cardiac cath with stent placement. The patient
has been symptomatic again with his typical exertional chest
pain for the last few weeks (responsive to Nitro). He was
recently ruled out for an MI during an admission from
[**Date range (1) 16589**] (also found to have ARF which resolved after IVF).
He was scheduled for an outpatient stress test on [**2149-4-3**]. The
exercise stress test was positive (6.75 minutes [**Doctor Last Name 4001**]
protocol, 66% max PHR, stopping due progressive anginal symptoms
with 9/10 arm pain radiating to the chest). The MIBI showed a
reversible defect in the lateral wall and he was sent for
cardiac cath on the day of admission.
.
A cypher stent was placed into LM/LAD. It was attempted to place
also a stent into the mid-distal LAD lesion but failed. During
the catheterization, he developed intermittent CP. His SBP went
up into the 220s and he received IV nitro. Next, the question of
a dissected LAD came up based on the angiographic image of the
wire. He received intracoronary Nitro (200 mcg) to dilate the
vessel and identify any dissection which could not be confirmed.
After this administration, his SBP dropped into the 70s and he
developed a vagal reaction with HR in upper 30s to lower 40s.
This event lasted approx 5 minutes and he responded to IV
atropin, very brief dopamine drip and IVF. There was no LOC but
some associated CP. There were transient ischemic changes during
the procedure (ST depressions in V4-V6). He was exposed to more
than 350cc of dye, about one hour of fluoro and he lost a
significant amount of blood. He received Angiomax in the cath
lab and was started on a bicarb drip. He next was transferred to
the CCU for monitoring after the above mentioned events.


Past Medical History:
Hypertension
Hyperlipidemia
Systolic CHF (EF 45%; [**5-7**])
[**5-7**]: STEMI; 3vCAD with subsequent CABG x 1
[**2138**] CVA
Carotid artery disease, s/p right CEA in [**2144**]
PVD (known bruit over right groin) with claudication
Gout
GERD
Lower back pain s/p L4-5 laminectomy
Nasal fractures, s/p surgical correction
Tonsillectomy


Social History:
100-pack-year history of smoking,and discontinued in [**2136**].
Social beer drinking (about 6 beers 3x/week). Married with four
children.

Family History:
Brother with ??????heart problems??????, died in his 40??????s.

Physical Exam:
VS: T BP 167/59 HR 59 RR 18 O2 100% RA
Gen: WDWN 77 year old male in NAD. Alert & Oriented. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very dry MM.
Neck: Supple without elevated JVP. Right carotic bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Soft, I/VI systolic murmur at apex, no rub or
gallop. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Cold feet b/l (chronic per patient). No femoral
bruits (but reportedly known right groin bruit pre-procedure -
not audible currently with gauze/tape covering groin).
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.


Pertinent Results:
Pre-cath EKG demonstrated normal sinus rhythm at 65 with normal
axis, normal intervals, no ST changes, old Q in III, old TWF in
aVF. Post-cath EKG showed transient ST depressions in V4-V6 (EKG
on next morning back to baseline).
.
2D-ECHOCARDIOGRAM performed on [**2148-5-20**] demonstrated: EF 45%
Pre revascularization:
1.No spontaneous echo contrast or thrombus is seen in the body
of the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. No left ventricular aneurysm
is seen. There is mild regional left ventricular systolic
dysfunction. Resting regional wall motion abnormalities include
mild hypokinesia of the mid and apical portions of the inferior
wall and the inferolateral walls.
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 complex (>4mm)
atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Mild (1+) to
moderate{ 2+} mitral regurgitation is seen. There is no
pericardial effusion.
.
Post revascularization:
1. Biventricular systolic function remains unchanged.
2. Mild to moderate mitral regurgitation persists.
.
CARDIAC CATH performed on [**2148-5-15**] demonstrated:
1. Selective coronary angiography demonstrated two vessel
coronary artery disease and branch vessel disease in this right
dominant circulation. The LMCA had proximal calcification with a
30% proximal stenosis. The LAD had a 40% proximal stenosis, a
70% D1 stenosis, and 70% origin stenoses in the S1 and S2. The
LCX had a 70% hazy origin stenosis with a 70% stenosis in the
OM2. The RCA was diffusely diseased and tortuous with a 70%
proximal stenosis, and a 95% distal stenosis that involved the
origin of the PDA that was occluded.
2. Right heart catheterization demonstrated normal right and
minimally elevated left sided filling pressures with RVEDP=7
mmHg and mean PCWP=12 mmHg. Pulmonary arterial pressure was
normal. Cardiac
output and index were 7.7 L/min and 3.8 L/min/m2 respectively.
3. Left ventriculogram was not performed to reduce constrast
load.
4. Right femoral Swan Ganz catheter and femoral venous
introducing
sheath were sutured for transport to intenstive care unit.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease with branch vessel
disease.
2. Normal RV diastolic function. Minimal LV diastolic
dysfunction.
.
CARDIAC CATH [**2149-4-4**]:
1. Selective coronary angiography of this right dominant system

demonstrated three vessel CAD. The LMCA had an 80% distal
stenosis. The LAD had an 80% ostial stenosis and 70% mid-distal
tubular lesion at the takeoff of the D1. The D1, S1, and S2 all
had 80% ostial lesions. The LCX ostium was subtotally occluded.
The OM1 filled via the patent SVG and both were free of
obstructive disease. The RCA was a small vessel and had
sequential 90% stenosis at mid and distal segments. The R-PDA
was totally occluded.
2. Conduit arterial angiography revealed patent single graft
(SVG-OM1).
3. Limited hemodynamic assessment demonstrated initial severe
hypertension (up to MAP of 130 mmHg) that was successfully
treated with intravenous nitroglycerine and a brief episode of
hypotension followed by bradycardia following the administration
of 200 mcg of IC nitro. This resolved shortly with treatment.
4. Left ventriculography was deferred.
5. The lesion in the ostial LAD was predilated with a 2.5mm
balloon,
stented with a 3.0 mm Cypher stent and post dilated with a 3.5
mm
balloon with lesion reduction to 0%. The final angiogram showed
TIMI III flow with no residual stenosis, no dissection, no
perforation and no embolisation. The patient left the lab in a
stable condition.
6. The ostium of the D2 was treated with POBA using a 2.5 mm
balloon.
Final angiogarm showed normal flow, minimal residual stenoses,
no
dissection, no perforation and no angiographic evidence of
distal
embolisation. The patient left the lab in a stable condition.
7. The mid LAD lesion was treated with POBA alone using a 2.5 mm
and a 3.0 mm balloon, as no stent could be delivered. The final
angiogram
showed TIMI III flow with <50% residual stenosis, no dissection,
no
perforation and no embolisation. The patient left the lab in a
stable
condition.
.
CXR [**2149-3-21**]: Comparison with [**2148-5-24**]. Slight improvement
in the cardiac shadow size. Left ventricular configuration still
remains. Aortic mural calcifications again noted. Tiny pleural
effusion. Lower lobe atelectasis. No evidence of failure.
Osseous structures unchanged. Changes of CABG.
.
[**2148-12-6**] LE ABI??????s: Right 0.75, left 0.71. Impression: bilateral
tibial disease.
.
Exercise MIBI [**2149-4-3**]:
1. New moderate, reversible defect involving the entire lateral

wall, at the level of exercise achieved. 2. Normal left
ventricular cavity size and function. Calculated EF 49%.
.
LABORATORY DATA (see attached):
normal chem7 (Cr of 1.3 pre-cath came down to 1.0 when arrived
in the CCU). WBC 5.7, Hct 35.8 (baseline 35-40), Plt 190


Brief Hospital Course:
This is a 77 year old male with h/o HTN, hyperlipidemia, PVD,
CVA, s/p right CEA, STEMI ([**5-7**]), 3vCAD s/p CAGB x1 (Dr. [**First Name (STitle) **]
[**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU monitoring
after cardiac cath with stent placement into LM/LAD, c/b
hypertensive urgency followed by hypotension and vagal reaction
with HR in high 30s after IV and intracoronary nitro
administration.
.
1) Hypotensive episode: This was likely due to a vagal reaction
after intracoronary nitro administration. Resolved after brief
dopamine drip, IVF and atropine for bradycardia.
.
2) CAD: s/p CABG x1 (Dr. [**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]), now
s/p cypher stent to LM/LAD and failed attempt to stent
mid-distal LAD. He had intermittent CP during cath with
transient ischemic changes on EKG. A post-cath check at midnight
was without significant hematoma or changes in pulses. Midnight
Hct was stable. Pt was continued on ASA, Plavix. Integrilin drip
for continued for 18 hours after the sheath was pulled. Nitro SL
prn CP was not needed b/o abscence of CP. Cardiac enzymes were
stable. He was monitored for significant blood loss after cath
but his Hct remained stable.
.
3) Rhythm: Bradycardic event resolved after Atropine
administration in cath lab. NSR on EKG.
.
4) Pump: EF of 45% and mild regional LV dysfunction on TTE from
[**5-7**]. Systolic CHF likely secondary to HTN. He will need to
follow up with his primary care physician, [**Name10 (NameIs) **] may need a follow
up TTE as an outpatient. He should follow a salt restricted
diet.
.
5) ARF: Cr of 1.3 prior to arrival in CCU. Recent ARF also
during last admission in [**3-8**] resolving after IVF. Cr was 1.0
when arrived in CCU. Pt received about 400cc of dye load during
cath. Bicarb drip was started in cath lab. He received post-cath
hydration with HCO3 drip for 1.5L at 100cc/h followed by D5
1/2NS at 100cc/h to prevent contrast-induced nephropathy. He
will have outpatient lab work on [**Date Range 766**] to check his creatinine.

.
6) Hyperlipidemia: continue statin
.
7) HTN: Pt was hypertensive during stenting followed by
hypotensive episode after IV and intracoronary nitro
administration. Normotensive when arrived in CCU.  On discharge
he was continued on his outpatient blood pressure meds
(lopressor and amlodipine).
.
8) PVD: Known bruit over right groin. S/p right CEA.
Claudication on history but palpable LE pulses. Outpatient
management recommended.
.
9) GERD: cont PPI.
.
10) FEN: Cardiac diet.
.
11) Code: Presumed full


Medications on Admission:
Aspirin 325mg daily every morning
Plavix 75mg daily every morning
Metoprolol 50mg twice a day
Zocor 40mg daily every evening
Prilosec 20mg every morning
Norvasc 5mg daily every morning


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
[**Date Range **]:*30 Tablet(s)* Refills:*3*
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Prilosec 20mg qday
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Outpatient Lab Work
Chem 7 on [**Last Name (LF) 766**], [**2149-4-7**].


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
1. 3 vessel CAD, s/p CAGB and stenting
2. HTN
3. Bradycardic, hypotensive episode responsive to fluids,
dopamine and atropine
.
Secondary diagnosis:
1. s/p CVA


Discharge Condition:
Hemodynamically stable, no chest pain, tolerating POs, no groin
bleeding.


Discharge Instructions:
You have been admitted for a cardiac catheterization. A stent
has been placed in one of your coronary arteries. You have
experienced prolonged radiation from the procedure. If you
experience any skin changes on your back, please go to your PCP
to have them evaluated.
.
Please call your PCP for any chest pain, shortness of breath,
fever, bleeding or any other concerning symptoms.

Followup Instructions:
Please have your kidney function checked by a blood test on
[**Year (4 digits) 766**] at your PCP's office. [**Last Name (LF) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 250**]
You will also need to see Dr. [**Last Name (STitle) **] within 1-2 weeks for a
full follow up appointment.



Completed by:[**2149-4-5**]
{'Cardiac complications, not elsewhere classified,Systolic heart failure, unspecified,Other and unspecified angina pectoris,Acute kidney failure, unspecified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia'}


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 s/p cardiac cath

PRESENT ILLNESS: 77 year old male with h/o HTN, EF 45%, hyperlipidemia, PVD, CVA,
s/p right CEA, STEMI (ST depressions in V2-V6 and 1mm STE in
III, 0.5mm STE in II and avF; [**5-7**]), 3vCAD s/p CAGB x1 (Dr.
[**First Name (STitle) **] [**Name (STitle) **]; SVG-0>OM1; [**5-7**]) who was admitted for CCU
monitoring after cardiac cath with stent placement. The patient
has been symptomatic again with his typical exertional chest
pain for the last few weeks (responsive to Nitro). He was
recently ruled out for an MI during an admission from
[**Date range (1) 16589**] (also found to have ARF which resolved after IVF).
He was scheduled for an outpatient stress test on [**2149-4-3**]. The
exercise stress test was positive (6.75 minutes [**Doctor Last Name 4001**]
protocol, 66% max PHR, stopping due progressive anginal symptoms
with 9/10 arm pain radiating to the chest). The MIBI showed a
reversible defect in the lateral wall and he was sent for
cardiac cath on the day of admission.
.
A cypher stent was placed into LM/LAD. It was attempted to place
also a stent into the mid-distal LAD lesion but failed. During
the catheterization, he developed intermittent CP. His SBP went
up into the 220s and he received IV nitro. Next, the question of
a dissected LAD came up based on the angiographic image of the
wire. He received intracoronary Nitro (200 mcg) to dilate the
vessel and identify any dissection which could not be confirmed.
After this administration, his SBP dropped into the 70s and he
developed a vagal reaction with HR in upper 30s to lower 40s.
This event lasted approx 5 minutes and he responded to IV
atropin, very brief dopamine drip and IVF. There was no LOC but
some associated CP. There were transient ischemic changes during
the procedure (ST depressions in V4-V6). He was exposed to more
than 350cc of dye, about one hour of fluoro and he lost a
significant amount of blood. He received Angiomax in the cath
lab and was started on a bicarb drip. He next was transferred to
the CCU for monitoring after the above mentioned events.

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Systolic CHF (EF 45%; [**5-7**])
[**5-7**]: STEMI; 3vCAD with subsequent CABG x 1
[**2138**] CVA
Carotid artery disease, s/p right CEA in [**2144**]
PVD (known bruit over right groin) with claudication
Gout
GERD
Lower back pain s/p L4-5 laminectomy
Nasal fractures, s/p surgical correction
Tonsillectomy

MEDICATION ON ADMISSION: Aspirin 325mg daily every morning
Plavix 75mg daily every morning
Metoprolol 50mg twice a day
Zocor 40mg daily every evening
Prilosec 20mg every morning
Norvasc 5mg daily every morning

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T BP 167/59 HR 59 RR 18 O2 100% RA
Gen: WDWN 77 year old male in NAD. Alert & Oriented. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Very dry MM.
Neck: Supple without elevated JVP. Right carotic bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Soft, I/VI systolic murmur at apex, no rub or
gallop. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Cold feet b/l (chronic per patient). No femoral
bruits (but reportedly known right groin bruit pre-procedure -
not audible currently with gauze/tape covering groin).
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: Brother with ??????heart problems??????, died in his 40??????s.

SOCIAL HISTORY: 100-pack-year history of smoking,and discontinued in [**2136**].
Social beer drinking (about 6 beers 3x/week). Married with four
children. 

### Response:
{'Cardiac complications, not elsewhere classified,Systolic heart failure, unspecified,Other and unspecified angina pectoris,Acute kidney failure, unspecified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia'}
