CHIEF COMPLAINT: CC: epigastric pain

PRESENT ILLNESS: 41yo F with Type I DM, HTN, hx renal transplant 4 years ago, and
recent admit for left heel cellulitis who presents after
developing CP that woke her from sleep at 3AM today. Has had
stuttering CP for 2 days but it has been constant since 3am.
Felt very weak and fatigued. Husband found her crawling up the
stairs of their home this AM, did not have the energy to change
her clothes. Took her to ER in pajamas. Has felt SOB and
fatigued for several weeks. Has had epigastric pain for the last
2 days which she thought was gas pain or her gastroparesis. Took
Tums w/ no relief. Developed back/shoulder pain o/n, again no
relief.
.
Came to ER in AM. Found to be hypotensive w/ SBP 87/46 (last BP
[**Last Name (un) **] was 146/79), HR 95, temp 96.3. Got EKG in ER which showed
ST elevations in II, III, avF and ST depressions in I, avL. Got
ASA, ativan, 1L NS, plavix 300x1, and heparin gtt. In cath lab,
found to have occluded RCA with difficult stent placement (no
reflow) that eventually required IC nipride injection to
establish flow.
.
During the procedure, pt's mived venous O2 sat dropped to 37%
and her CI fell to less than 2.0. She became agitated and had
mental status changes, making her unable to comply with keeping
her leg straight. She was intubated for SOB and agitation. After
intubation, MV02 improved to 58%. ABG 7.18/27/373 w/ bicarb 11,
BE -16. Sent to CCU for further monitoring.

MEDICAL HISTORY: PMH:
ESRD s/p LRRT 4 years ago
Type I DM since [**58**] yo, triopathy
HTN
CRI
PVD
Left LE ulcer/cellulitis with recent admit
Gastroparesis
Hyperlipidemia
.
[**Doctor First Name 147**] HX:
Laser treatment to eye
hx right breast lump s/p resection
LRRT in [**2146**]

MEDICATION ON ADMISSION: Tacrolimus 2mg PO BID
sirolimus 4mg PO QD
pravastatin 10mg PO QD
Bactrim 1 DS TIW
Percocet PRN
ranitidine 150mg [**Hospital1 **]
silvadene 1% cream topical [**Hospital1 **]

ALLERGIES: Levofloxacin

PHYSICAL EXAM: VS: T 94.7, BP 106/63 (161/87), HR 94-104, RR 19-22, sats 100%
Vent: AC Tv 450 (actual 500), RR 10, Fi02 60%, PIP 16, Peak 14
HEENT: Sclera anicteric.
NECK: Neck supple, no appreciable JVD
LUNGS: CTA anteriorly and at bases, no crackles, wheezes,
rhonchi.
HEART: Tachycardic, regular. Normal S1, S2. No m/r/g.
ABD: Soft, NTND. + BS, no masses. Scar in LLQ from kidney
transplant.
EXT: No edema. 2+ PT, DP pulses bilaterally.
NEURO: Sedated, but moving all 4 ext spontaneously.
SKIN: No rashes.

FAMILY HISTORY: + CAD, hypercholesterolemia, HTN, cancer

SOCIAL HISTORY: Lives w/ husband in [**Name (NI) 16848**], MA. + tobacco in past, no tob or
EtOH currently.
Acute myocardial infarction of other inferior wall, initial episode of care,Systolic heart failure, unspecified,Paroxysmal ventricular tachycardia,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Ulcer of heel and midfoot,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,First degree atrioventricular block,Acidosis,Gastroparesis,Polyneuropathy in diabetes,Peripheral autonomic neuropathy in disorders classified elsewhere,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Other specified hypotension,Peripheral vascular disease, unspecified,Anemia in chronic kidney disease
AMI inferior wall, init,Systolic hrt failure NOS,Parox ventric tachycard,Compl kidney transplant,Ac kidny fail, tubr necr,Ulcer of heel & midfoot,DMI neuro nt st uncntrld,Atriovent block-1st degr,Acidosis,Gastroparesis,Neuropathy in diabetes,Aut neuropthy in oth dis,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Hypotension NEC,Periph vascular dis NOS,Anemia in chr kidney dis
Admission Date:  [**2150-3-9**]              Discharge Date:   [**2150-3-16**]

Date of Birth:  [**2108-4-25**]             Sex:   F

Service: MEDICINE

Allergies:
Levofloxacin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
CC: epigastric pain

Major Surgical or Invasive Procedure:
Cardiac catheterization w/ DES placed to proximal and mid RCA
Intubation and mechanical ventilation
R IJ placement and removal


History of Present Illness:
41yo F with Type I DM, HTN, hx renal transplant 4 years ago, and
recent admit for left heel cellulitis who presents after
developing CP that woke her from sleep at 3AM today. Has had
stuttering CP for 2 days but it has been constant since 3am.
Felt very weak and fatigued. Husband found her crawling up the
stairs of their home this AM, did not have the energy to change
her clothes. Took her to ER in pajamas. Has felt SOB and
fatigued for several weeks. Has had epigastric pain for the last
2 days which she thought was gas pain or her gastroparesis. Took
Tums w/ no relief. Developed back/shoulder pain o/n, again no
relief.
.
Came to ER in AM. Found to be hypotensive w/ SBP 87/46 (last BP
[**Last Name (un) **] was 146/79), HR 95, temp 96.3. Got EKG in ER which showed
ST elevations in II, III, avF and ST depressions in I, avL. Got
ASA, ativan, 1L NS, plavix 300x1, and heparin gtt. In cath lab,
found to have occluded RCA with difficult stent placement (no
reflow) that eventually required IC nipride injection to
establish flow.
.
During the procedure, pt's mived venous O2 sat dropped to 37%
and her CI fell to less than 2.0. She became agitated and had
mental status changes, making her unable to comply with keeping
her leg straight. She was intubated for SOB and agitation. After
intubation, MV02 improved to 58%. ABG 7.18/27/373 w/ bicarb 11,
BE -16. Sent to CCU for further monitoring.


Past Medical History:
PMH:
ESRD s/p LRRT 4 years ago
Type I DM since [**58**] yo, triopathy
HTN
CRI
PVD
Left LE ulcer/cellulitis with recent admit
Gastroparesis
Hyperlipidemia
.
[**Doctor First Name 147**] HX:
Laser treatment to eye
hx right breast lump s/p resection
LRRT in [**2146**]

Social History:
Lives w/ husband in [**Name (NI) 16848**], MA. + tobacco in past, no tob or
EtOH currently.

Family History:
+ CAD, hypercholesterolemia, HTN, cancer

Physical Exam:
VS: T 94.7, BP 106/63 (161/87), HR 94-104, RR 19-22, sats 100%
Vent: AC Tv 450 (actual 500), RR 10, Fi02 60%, PIP 16, Peak 14
HEENT: Sclera anicteric.
NECK: Neck supple, no appreciable JVD
LUNGS: CTA anteriorly and at bases, no crackles, wheezes,
rhonchi.
HEART: Tachycardic, regular. Normal S1, S2. No m/r/g.
ABD: Soft, NTND. + BS, no masses. Scar in LLQ from kidney
transplant.
EXT: No edema. 2+ PT, DP pulses bilaterally.
NEURO: Sedated, but moving all 4 ext spontaneously.
SKIN: No rashes.

Pertinent Results:
LABS on admission:

MICRO:
[**2150-3-9**]: blood cx negative
[**2150-3-9**]: urine cx negative
[**2150-3-10**]: blood cx (mycolytics/fungal isolators) negative
[**2150-3-10**]: blood cx negative x2
[**2150-3-10**]: urine cx negative
[**2150-3-11**]: C diff negative
[**2150-3-13**]: urine cx negative
[**2150-3-15**]: C diff pending
.
IMAGING:
[**2150-3-9**] CATH:
RA 19/21/17
RV 32/19
PA 32/21/26
WEDGE 25/28/22
AORTA 99/61/74
CO/CI 3.9/2.7 -> 2.27/1.54
SVR 1169
.
1. Selective coronary angiography revealed a right dominant
system with severe diffuse disease. The LAD was totally occluded
in the mid-vessel. There was a diffusely diseased bifurcating
large diagonal up to 70%. The LCX had a 70% lesion in the mid
vessel. There was a totally occluded OM. The RCA was 100%
occluded proximally, which was thought to be the culprit lesion.

2. Hemodynamics post intervention revealed elevated filling
pressures
(RVEDP 19 mm Hg, PCWP mean 22 mm Hg) with hemodynamics
consistent w/
RV infarction. Initially patient was somewhat hypotensive,
requiring
dopamine. Post intervention, patient's blood pressure improved
and
dopamine was discontinued. Post intervention CI was 2.01, with
arterial pH of 7.17. Repeat CI was 1.5 with a arterial pH of
7.23; at that time patient had SBP >120.
3. Patient became increasingly agitated post intervention with
mental
status changes and metabolic acidosis. She was unable to lay
flat with sheaths in her groin. She was intubated and sent to
the CCU.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated filling pressures consistent with RV infarction.
3. Low cardiac index and acidemia without hypotension.
.
[**2150-3-9**] ECHO: There is symmetric left ventricular hypertrophy.
There is severe regional left ventricular systolic dysfunction
(EF 25%) with akinesis of the inferior wall, infero-septum and
apex. The antero-septum is hypokinetic. The basal to mid
anterior and lateral walls move best. There is moderate
spontaneous echo contrast seen in the LV cavity but no masses or
thrombi are seen. There is severe global right ventricular free
wall hypokinesis. The pulmonary artery
systolic pressure could not be determined. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade. IMPRESSION: Severe,
regional LV systolic dysfunction c/w multivessel CAD. RV
systolic dysfunction.
.
[**2150-3-9**] CXR: Endotracheal tube tip in satisfactory position
.
[**2150-3-9**] CXR: There has been interval placement of a right
internal jugular vascular catheter, with the tip terminating in
the region of the junction of the superior vena cava and right
atrium.  There is no evidence of pneumothorax, and there has
otherwise been no significant change since the recent study of
several hours earlier.
.
[**2150-3-9**] RENAL U/S: Unremarkable transplant kidney without
hydronephrosis.
.
[**2150-3-10**] CXR: AP single view of the chest obtained with patient
in semi-upright position is analyzed in direct comparison with a
similar previous study obtained on [**2150-3-9**]. The
patient remains intubated, the ETT in unchanged position. The
same holds for an internal jugular approach central venous line
terminating at the cavo-atrial junction and a Swan-Ganz catheter
approached from below terminating in the main pulmonary artery.
NG tube reaches stomach. Patient is less inflated during this
exposure in comparison with the previous study. There is no
evidence of new parenchymal densities or CHF but the pulmonary
vasculature is slightly more crowded. The lateral pleural
sinuses remain free.


Brief Hospital Course:
41yo F w/ DMI s/p LRRT [**2146**] and recent hospitalization for L
heel ulcer, presents w/ inferior STEMI with course complicated
by ARF.
.
# ISCHEMIA: Ms. [**Known lastname **] presented with an inferior STEMI. On
admission CK 361, MB 18, MBI 5.0, trop 2.66). She was taken
straight to the cath lab where she was found to have diffuse
disease, but total occlusion of her RCA which was felt to be the
culprit lesion. Two [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] were placed in the RCA, but they
were unable to establish good reflow post-stenting. IC nipride
was injected and good flow was eventually established. She was
also started on Reopro in the cath lab. PA sats were as low as
37% intra-procedure, but improved to 59% after intubation. ABGs
in cath lab showed an acidemia (pH 7.18) and her lactate was
9.1. IABP was not placed secondary to her severe PVD. In the
cath lab, she initially required a dopamine gtt to keep her BP
up, but by the end of the procedure, she had to be given nipride
to control her BP. Her CO and CI were low and overnight,
dobutamine was added for inotropy. With the addition of
dobutamine, her PA sats improved to 70%, her lactate came down
to 1.3, and her UOP improved to 40cc/hr. Her enzymes peaked at
CK of 1124, MB of 34, and troponin of 6.35. She had persistent
ST elevations on EKG after her intervention, and they remained
on EKG throughout the rest of her hospitalization. She remained
chest pain free after her extubation, although she had
intermittent episodes of epigastric discomfort that were not
associated with any EKG changes. These were felt to most likely
be related to her gastroparesis and GERD. She was continued on
aspirin and plavix after the placement of her stents. She was
continued on her outpatient dose of pravachol for secondary MI
prevention. She was started on coreg with good effect on her BP
and HR. Despite her depressed EF, an ACE inhibitor was not
started given her acute renal failure. It was felt that the
decision to start an ACE inhibitor could be delayed to the
outpatient setting.  She will follow-up with Dr. [**Last Name (STitle) **] in [**1-19**]
weeks.
.
# PUMP: An ECHO was performed in the cath lab and showed an EF
of 20-25%, with apical and inferior akinesis and a small
pericardial effusion. A repeat TTE on the floor was unchanged,
with no increase in pericardial effusion and no evidence
tamponade physiology. She unfortunately did not show any
improvement in her EF, either. Her CO and CI were low on
transfer from the CCU, and dobutamine was started with
improvement in both. The dobutamine was able to be weaned off on
[**2150-3-10**]. She had minimal urine output for the first several days
of her hospitalization, which caused her to become volume
overloaded. She was not diuresed, however, due to her renal
failure and Renal never felt that HD was indicated. She
eventually began to autodiurese and mobilize her extra fluid on
her own. She was advised to follow a low [**Date Range **] diet in order to
prevent further fluid accumulation. For medical management of
her heart failure, she was started on coreg but ACE inhibitors
had to be held secondary to her renal failure. ECHO confirmed an
akinetic apex, but it was not felt to be acute thus there was no
need for anticoagulation currently.  She will need a repeat echo
in 1 month's time, at which time, if she has not had improvement
in her EF, she will be considered for placement of an ICD.
.
# RHTYHM: She remained in NSR for most of her stay. She
displayed a prolonged PR interval during her first hospital day,
but her PR was back down to 0.186 by [**3-10**]. She was monitored on
telemetry while she was here and had frequent EKGs which showed
slowly resolving ST elevations in the inferior leads.
.
# ARF: Renal was consulted because of her history of a living
related donor renal transplant and her chronic
immunosuppression. It was felt that her ARF was multifactorial,
with components of ATN, prerenal azotemia, and contrast-induced
nephropathy. Her Cr peaked at 4.3 and then trended down. She
never became anuric, but her immunosuppression did have to be
held for several days based on elevated troughs and likely poor
clearance. Despite becoming fluid overloaded, she never
developed any respiratory symptoms and was able to remain on RA
without any changes in her oxygen saturation. Renal helped
manage her electrolytes, with the intermittent use of bicitra
and phoslo. She was restarted on her immunosuppression once her
CrCl began to improve. She will follow up with renal in [**1-19**]
weeks after discharge, but will have her immunosuppression
levels checked by her PCP in order to guage the changes in the
doses of her immunosuppression with the improvement of her
creatinine.
.
# METABOLIC ACIDOSIS: On admission, she had a pure anion gap
metabolic acidosis, likely related her elevated lactate from
hypoperfusion. The gap was slow to resolve, however, in spite of
improvement in her lactate. It was felt that early renal failure
was also a component as it required the addition of bicitra to
bring her gap back to normal.
.
# ANEMIA: She was anemic on admission. Anemia workup revealed a
mixed picture, likely ACD as well as iron deficiency. She was
started on iron supplementation as well as Epo injections
briefly. Her Hct improved and renal decided she no longer needed
the Epo injections, but did recommend that she continue on iron
supplements.
.
# DM TYPE I: Ms. [**Known lastname **] is a lifelong diabetic with poor glucose
control. Since [**2147**], her HgbA1c has not been <11.3. She was
originally started on an insulin gtt and [**Last Name (un) **] was consulted
for help in managing her insulin regimen. She was titrated off
the insulin gtt and started on Lantus QAM with a RISS. Her
fingersticks were under modest control on this regimen, and the
patient liked this regimen more than the regimen of NPH that she
had been taking at home.
.
# LEFT HEEL ULCER: Ms. [**Known lastname **] had recently been admitted for a
deep L heel ulcer. Podiatry was notified of her admission and
consulted on her while she was here. She was originally started
on vancomycin and zosyn because she was febrile on admission and
there was concern for sepsis, given her hypotension, low SVR,
and fevers. However, her heel ulcer seemed to be healing and she
became afebrile. Her hemodynamics began to improve and she
became afebrile, so vancomycin and zosyn were discontinued.
Podiatry felt that she needed continued abx as she was at high
risk for infection so she was started on PO dicloxacillin which
she seemed to tolerate well. Podiatry also recommended that she
be seen by vascular surgery as an inpatient, and they
recommended imaging (MRI/MRA) but the patient refused. She will
be set up to see vascular surgery as an outpatient once her ARF
resolves and she is more willing to take IV contrast again.
Podiatry also made recommendations as to optimal wound care for
her L heel ulcer. She will follow-up with Dr. [**Last Name (STitle) **] in [**7-27**]
after discharge.
.
#. FEN: She was given a cardiac, heart healthy, low [**Last Name (LF) **], [**First Name3 (LF) **]
diet. She received no IVF during her stay due to her volume
status. She did, however, receive two units of pRBCs because of
an acute drop in her hematocrit after her catheterization. Her
electrolytes were checked regularly and were repleted to keep
her K >4 and Mg >2.
.
#. ACCESS: Originally, she had a venous and arterial sheath left
in place post-catheterization. They were pulled and she was
given a R IJ and a R art line instead. Once she was called out
of the unit, both her central line and arterial line were pulled
and she was managed on the floor with just peripheral IV access.

.
#. PPX: Pneumoboots for DVT prophylaxis. She was given a PPI for
her GERD/GI issues. No bowel regimen was needed given her
diarrhea. Incentive spirometer.
.
#. CODE: FULL
.
#. DISPO: Home w/ services (home PT and VNA for wound care).
Follow-up appointments were scheduled with: cardiology, GI,
vascular surgery, renal, podiatry and [**Last Name (un) **].

Medications on Admission:
Tacrolimus 2mg PO BID
sirolimus 4mg PO QD
pravastatin 10mg PO QD
Bactrim 1 DS TIW
Percocet PRN
ranitidine 150mg [**Hospital1 **]
silvadene 1% cream topical [**Hospital1 **]

D/c [**2-9**] from podiatry on abx:
dicloxacillin 500mg PO QID x 2weeks
levofloxacin 500mg PO QD x 2weeks

Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Dicloxacillin 250 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 3 weeks.
Disp:*84 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Primary diagnosis:
Inferior ST elevation MI
Systolic heart failure (EF 20-25%)
Acute renal failure
.
Secondary diagnosis:
L heel ulcer
Diabetes mellitus type I


Discharge Condition:
Good. Afebrile, BP stable, chest pain free.


Discharge Instructions:
1. Please call your PCP or go to the nearest ER if you develop
any of the following symptoms: chest pain, palpitations,
shortness of breath, difficulty breathing, epigastric pain or
burning, fevers, chills, leg swelling or numbness, increase in
weight, decreased urination, or any other worrisome symptoms.
2. Please take all your medications as prescribed, especially
your aspirin and plavix. These medications need to be taken
every day to help keep your stents open.
3. Please keep all your follow-up appointments.

Followup Instructions:
1. Please follow-up with your PCP [**Last Name (NamePattern4) **] 1 week. You will need to
have all of your electrolytes checked, including your BUN and
Cr.  Please ask to have these faxed to your kidney doctors.
[**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 250**].
2. Please follow-up with Dr. [**Last Name (STitle) **] (cardiology) on [**2150-3-24**] at
11:30 in [**Hospital Ward Name 23**] 7.  Phone # ([**Telephone/Fax (1) 5909**].
3. Please follow-up with Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2625**]
(vascular surgery) on [**2150-4-8**] at 2:30 PM
4. Please follow-up with Dr. [**Last Name (STitle) **] (podiatry) in Provider:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2150-3-18**] 9:30
5. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9978**] ([**Hospital **] clinic) on
[**2150-3-19**] at 8:30 AM on the [**Location (un) **] [**Telephone/Fax (1) 2378**].
6. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] M.D./Dr. [**Last Name (STitle) 4920**]
(renal) on [**2150-3-27**] 9:50 AM at the [**Hospital Unit Name **] [**Location (un) 436**]
[**Telephone/Fax (1) 23134**].
7. Please follow-up with [**Name6 (MD) **] [**Last Name (NamePattern4) 25130**], M.D.
(gastroenterology) on [**2150-5-11**] at 11:00am. If you have any
questions or need to reschedule this appointment, please call
his office at [**Telephone/Fax (1) 1954**].
8. Please follow-up for a repeat echocardiogram of your heart on
[**2150-4-15**] 11:00 AM at the [**Hospital Ward Name 2104**] building [**Location (un) **] of [**Hospital1 1535**] [**Hospital Ward Name 516**].  The day after your
echocardiogram, please call Dr.[**Name (NI) 5907**] office and inquire
about a follow-up appointment to review the results.



Completed by:[**2150-3-17**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Systolic heart failure, unspecified,Paroxysmal ventricular tachycardia,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Ulcer of heel and midfoot,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,First degree atrioventricular block,Acidosis,Gastroparesis,Polyneuropathy in diabetes,Peripheral autonomic neuropathy in disorders classified elsewhere,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Other specified hypotension,Peripheral vascular disease, unspecified,Anemia in chronic kidney disease'}


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: CC: epigastric pain

PRESENT ILLNESS: 41yo F with Type I DM, HTN, hx renal transplant 4 years ago, and
recent admit for left heel cellulitis who presents after
developing CP that woke her from sleep at 3AM today. Has had
stuttering CP for 2 days but it has been constant since 3am.
Felt very weak and fatigued. Husband found her crawling up the
stairs of their home this AM, did not have the energy to change
her clothes. Took her to ER in pajamas. Has felt SOB and
fatigued for several weeks. Has had epigastric pain for the last
2 days which she thought was gas pain or her gastroparesis. Took
Tums w/ no relief. Developed back/shoulder pain o/n, again no
relief.
.
Came to ER in AM. Found to be hypotensive w/ SBP 87/46 (last BP
[**Last Name (un) **] was 146/79), HR 95, temp 96.3. Got EKG in ER which showed
ST elevations in II, III, avF and ST depressions in I, avL. Got
ASA, ativan, 1L NS, plavix 300x1, and heparin gtt. In cath lab,
found to have occluded RCA with difficult stent placement (no
reflow) that eventually required IC nipride injection to
establish flow.
.
During the procedure, pt's mived venous O2 sat dropped to 37%
and her CI fell to less than 2.0. She became agitated and had
mental status changes, making her unable to comply with keeping
her leg straight. She was intubated for SOB and agitation. After
intubation, MV02 improved to 58%. ABG 7.18/27/373 w/ bicarb 11,
BE -16. Sent to CCU for further monitoring.

MEDICAL HISTORY: PMH:
ESRD s/p LRRT 4 years ago
Type I DM since [**58**] yo, triopathy
HTN
CRI
PVD
Left LE ulcer/cellulitis with recent admit
Gastroparesis
Hyperlipidemia
.
[**Doctor First Name 147**] HX:
Laser treatment to eye
hx right breast lump s/p resection
LRRT in [**2146**]

MEDICATION ON ADMISSION: Tacrolimus 2mg PO BID
sirolimus 4mg PO QD
pravastatin 10mg PO QD
Bactrim 1 DS TIW
Percocet PRN
ranitidine 150mg [**Hospital1 **]
silvadene 1% cream topical [**Hospital1 **]

ALLERGIES: Levofloxacin

PHYSICAL EXAM: VS: T 94.7, BP 106/63 (161/87), HR 94-104, RR 19-22, sats 100%
Vent: AC Tv 450 (actual 500), RR 10, Fi02 60%, PIP 16, Peak 14
HEENT: Sclera anicteric.
NECK: Neck supple, no appreciable JVD
LUNGS: CTA anteriorly and at bases, no crackles, wheezes,
rhonchi.
HEART: Tachycardic, regular. Normal S1, S2. No m/r/g.
ABD: Soft, NTND. + BS, no masses. Scar in LLQ from kidney
transplant.
EXT: No edema. 2+ PT, DP pulses bilaterally.
NEURO: Sedated, but moving all 4 ext spontaneously.
SKIN: No rashes.

FAMILY HISTORY: + CAD, hypercholesterolemia, HTN, cancer

SOCIAL HISTORY: Lives w/ husband in [**Name (NI) 16848**], MA. + tobacco in past, no tob or
EtOH currently. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Systolic heart failure, unspecified,Paroxysmal ventricular tachycardia,Complications of transplanted kidney,Acute kidney failure with lesion of tubular necrosis,Ulcer of heel and midfoot,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,First degree atrioventricular block,Acidosis,Gastroparesis,Polyneuropathy in diabetes,Peripheral autonomic neuropathy in disorders classified elsewhere,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Other specified hypotension,Peripheral vascular disease, unspecified,Anemia in chronic kidney disease'}
