CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: This is a 78 year old female with history of hypertension,
hypothyroidism presenting with chest pain over the last week.
The chest pain had been intermittent until this morning of
admission around 10 AM while driving back from the grocery
store, when it became constant. She denied shortness of breath,
nausea, vomiting, diaphoresis at the time. She presented to the
ED, vital signs were HR:46 BP:129/70 Resp:18 O(2)Sat:100% 2L NC.
She had an EKG that showed rate 47, atrial fibrillation, axis
slight right axis deviation, ST elevations in II, III, AVF, V3-5
and reciprocal depressions in I, aVL, V1, V2 with inverted T
waves in I, aVL, V1, V2; ST segments resolved in precordial
leads; ? q waves in lead V1. A right sided EKG showed signifacnt
ST elevations in V3-6. Patient was taken to the cath lab and had
a V-fib arrest for less than 1 minute. She was shocked x2 and
given epi x1 and amio x1 after which she resumed her baseline
rhythm of atrial fibrillation with slow ventricular rates. At
this time she was also started on levophed and dopamine for MAPs
< 60s. She was transferred to the CCU; vitals at time of
transfer showed HRs of 70s in atrial fibrillation, BP of 115/70,
intubated, but responsive to instructions.

MEDICAL HISTORY: 1. Hypothyroidism diagnoised more than 30 years ago
2. Atrial fibrillation
3. Hypertension
4. Frequent UTIs
5. Osteoarthritis
6. IBS

MEDICATION ON ADMISSION: AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
CELECOXIB [CELEBREX] - 200 mg Capsule - 1 (One) Capsule(s) by
mouth once a day
LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet - 1 (One) Tablet(s)
by
mouth once a day and extra [**12-16**] tablet once weekly - No
Substitution
LISINOPRIL - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day
qhs
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 (One) Tablet(s) by
mouth
once weekly - No Substitution
WARFARIN [COUMADIN] - 5 mg Tablet - 1 Tablet(s) by mouth at
bedtime as directed by your primary care doctor, based on INR
readings

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Strawberry

PHYSICAL EXAM: GEN: Caucasian female, intubated, off sedation able to follow
instructions
Neuro: Positive for dysmetria on cerebellar testing, difficulty
with finger to nose
CARDIAC: Nl s1/s2, RRR no murmurs appreciable
RESP: Lungs clear bilaterally, no rales appreciable
ABD: Soft, nontender, nondistended, no hepatosplenomegaly, no
masses palpable
Ext: soft, absent pulses in right lower extremity, left lower
extremity 1+ pulses distally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Non-contributory
Acute myocardial infarction of other inferior wall, initial episode of care,Ventricular fibrillation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Lack of coordination,Unspecified hemorrhoids with other complication,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Other and unspecified noninfectious gastroenteritis and colitis,Osteoporosis, unspecified,Personal history, urinary (tract) infection,Long-term (current) use of anticoagulants,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
AMI inferior wall, init,Ventricular fibrillation,Urin tract infection NOS,Surg compl-heart,Atriovent block complete,Crnry athrscl natve vssl,Hypotension NOS,Lack of coordination,Hemrrhoid NOS w comp NEC,Retention urine NOS,Hypothyroidism NOS,Noninf gastroenterit NEC,Osteoporosis NOS,Personal history UTI,Long-term use anticoagul,Abn react-cardiac cath,Accid in resident instit
Admission Date:  [**2171-3-29**]              Discharge Date:   [**2171-4-5**]

Date of Birth:  [**2093-1-4**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Strawberry

Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
cardiac catheterization with drug eluting stents x3 to proximal
right coronary artery
pulmonary intubation


History of Present Illness:
This is a 78 year old female with history of hypertension,
hypothyroidism presenting with chest pain over the last week.
The chest pain had been intermittent until this morning of
admission around 10 AM while driving back from the grocery
store, when it became constant. She denied shortness of breath,
nausea, vomiting, diaphoresis at the time. She presented to the
ED, vital signs were HR:46 BP:129/70 Resp:18 O(2)Sat:100% 2L NC.
She had an EKG that showed rate 47, atrial fibrillation, axis
slight right axis deviation, ST elevations in II, III, AVF, V3-5
and reciprocal depressions in I, aVL, V1, V2 with inverted T
waves in I, aVL, V1, V2; ST segments resolved in precordial
leads; ? q waves in lead V1. A right sided EKG showed signifacnt
ST elevations in V3-6. Patient was taken to the cath lab and had
a V-fib arrest for less than 1 minute. She was shocked x2 and
given epi x1 and amio x1 after which she resumed her baseline
rhythm of atrial fibrillation with slow ventricular rates. At
this time she was also started on levophed and dopamine for MAPs
< 60s. She was transferred to the CCU; vitals at time of
transfer showed HRs of 70s in atrial fibrillation, BP of 115/70,
intubated, but responsive to instructions.

Past Medical History:
1. Hypothyroidism diagnoised more than 30 years ago
2. Atrial fibrillation
3. Hypertension
4. Frequent UTIs
5. Osteoarthritis
6. IBS

Social History:
Non-contributory

Family History:
Non-contributory

Physical Exam:
GEN: Caucasian female, intubated, off sedation able to follow
instructions
Neuro: Positive for dysmetria on cerebellar testing, difficulty
with finger to nose
CARDIAC: Nl s1/s2, RRR no murmurs appreciable
RESP: Lungs clear bilaterally, no rales appreciable
ABD: Soft, nontender, nondistended, no hepatosplenomegaly, no
masses palpable
Ext: soft, absent pulses in right lower extremity, left lower
extremity 1+ pulses distally

Pertinent Results:
Labs on Admission:
[**2171-3-29**] 11:44PM   SODIUM-139 POTASSIUM-3.9 CHLORIDE-104
[**2171-3-29**] 11:44PM   CK-MB-81*
[**2171-3-29**] 11:44PM   PLT COUNT-284
[**2171-3-29**] 04:47PM   TYPE-ART TEMP-37.2 PO2-92 PCO2-35 PH-7.39
TOTAL CO2-22 BASE XS--2
[**2171-3-29**] 04:47PM   GLUCOSE-186* LACTATE-2.1*
[**2171-3-29**] 04:47PM   O2 SAT-95
[**2171-3-29**] 03:26PM   GLUCOSE-272* UREA N-23* CREAT-0.9 SODIUM-139
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2171-3-29**] 03:26PM   ALT(SGPT)-282* AST(SGOT)-449* LD(LDH)-684*
CK(CPK)-1084* ALK PHOS-86 TOT BILI-0.8
[**2171-3-29**] 03:26PM   CK-MB-87* MB INDX-8.0* cTropnT-2.68*
[**2171-3-29**] 03:26PM   ALBUMIN-3.9 CALCIUM-9.0 PHOSPHATE-3.3
MAGNESIUM-1.4*
[**2171-3-29**] 03:26PM   WBC-15.1* RBC-4.87 HGB-14.6 HCT-42.0 MCV-86
MCH-30.0 MCHC-34.8 RDW-14.6
[**2171-3-29**] 03:26PM   PLT COUNT-300
[**2171-3-29**] 03:23PM   PT-23.0* PTT-27.2 INR(PT)-2.1*
[**2171-3-29**] 12:57PM   TYPE-ART TIDAL VOL-500 O2-100 PO2-387*
PCO2-38 PH-7.32* TOTAL CO2-20* BASE XS--5 AADO2-295 REQ O2-55
-ASSIST/CON INTUBATED-INTUBATED
[**2171-3-29**] 12:57PM   GLUCOSE-284*
[**2171-3-29**] 12:57PM   HGB-14.6 calcHCT-44 O2 SAT-97
[**2171-3-29**] 12:20PM   TYPE-ART O2 FLOW-15 PO2-273* PCO2-72* PH-7.37
TOTAL CO2-43* BASE XS-13 -ASSIST/CON INTUBATED-NOT INTUBA
[**2171-3-29**] 12:20PM   LACTATE-4.9* K+-4.4 CL--104
[**2171-3-29**] 12:20PM   HGB-14.1 calcHCT-42 O2 SAT-98
[**2171-3-29**] 11:20AM   GLUCOSE-188* UREA N-22* CREAT-0.9 SODIUM-142
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-30 ANION GAP-17
[**2171-3-29**] 11:20AM   estGFR-Using this
[**2171-3-29**] 11:20AM   cTropnT-<0.01
[**2171-3-29**] 11:20AM   CALCIUM-10.1 PHOSPHATE-3.6 MAGNESIUM-1.6
[**2171-3-29**] 11:20AM   WBC-10.4 RBC-5.19 HGB-15.6 HCT-45.0 MCV-87
MCH-30.1 MCHC-34.7 RDW-14.8
[**2171-3-29**] 11:20AM   NEUTS-67.9 LYMPHS-25.1 MONOS-5.1 EOS-1.3
BASOS-0.5
[**2171-3-29**] 11:20AM   PLT COUNT-307
[**2171-3-29**] 11:20AM   PT-22.7* PTT-23.2 INR(PT)-2.1*

Labs on Discharge:
[**2171-4-5**] 07:46AM BLOOD WBC-14.4* RBC-4.84 Hgb-14.1 Hct-42.1
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.4 Plt Ct-519*
[**2171-4-5**] 07:46AM BLOOD PT-36.7* INR(PT)-3.7*
[**2171-4-5**] 07:46AM BLOOD Glucose-143* UreaN-24* Creat-1.0 Na-137
K-3.9 Cl-100 HCO3-27 AnGap-14
[**2171-4-4**] 07:45AM BLOOD ALT-38 AST-39 LD(LDH)-392* AlkPhos-53
TotBili-0.6
[**2171-3-30**] 11:37AM BLOOD CK-MB-21* MB Indx-2.6 cTropnT-4.14*
[**2171-4-5**] 07:46AM BLOOD Phos-3.4 Mg-1.5*
[**2171-4-2**] 07:27AM BLOOD TSH-6.7*
[**2171-4-4**] 07:45AM BLOOD Free T4-0.92*
[**2171-3-31**] 05:04PM BLOOD Lactate-1.5
[**2171-4-3**] 09:19AM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-SM  Urobiln-2* pH-6.0 Leuks-NEG
[**2171-4-3**] 09:19AM URINE RBC-13* WBC-7* Bacteri-FEW Yeast-NONE
Epi-0

Microbiology:
[**2171-3-30**] Blood culture x 2 NEGATIVE
[**2171-3-30**] 3:36 am URINE      Source: Catheter.

                            **FINAL REPORT [**2171-3-31**]**

   URINE CULTURE (Final [**2171-3-31**]):
      GRAM NEGATIVE ROD(S).    ~3000/ML

[**3-31**] and [**2171-4-2**] C. Diff [**Doctor First Name **] negative x 2
[**2171-4-3**] 9:19 am URINE      Source: CVS.

   URINE CULTURE (Preliminary):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.
      GRAM POSITIVE BACTERIA.    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------       R
CEFTRIAXONE-----------  =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

Imaging:
Cardiac Cath	Study Date of [**2171-3-29**]
HEMODYNAMICS RESULTS	BODY SURFACE AREA: 	1.66 m2
 	HEMOGLOBIN:	15.6 gms %
 	FICK	 	
**PRESSURES
RIGHT ATRIUM {a/v/m}	-/30/25	 	
RIGHT VENTRICLE {s/ed}	47/25	 	
PULMONARY ARTERY {s/d/m}	47/30/36	 	
PULMONARY WEDGE {a/v/m}	-/38/30	 	
AORTA {s/d/m}	131/70/94	 	
**CARDIAC OUTPUT
HEART RATE {beats/min}	88	 	
RHYTHM	AFIB	 	
O2 CONS. IND {ml/min/m2}	125	 	
A-V O2 DIFFERENCE {ml/ltr}	36	 	
CARD. OP/IND FICK {l/mn/m2}	5.8/3.5	 	
**RESISTANCES
SYSTEMIC VASC. RESISTANCE	952	 	
PULMONARY VASC. RESISTANCE	83	 	
 	 	 	
**% SATURATION DATA (NL)
PA MAIN	81	 	
AO	98	 	

OTHER HEMODYNAMIC DATA:      The oxygen consumption was assumed.

**PTCA RESULTS
 	RCA	 	 	 	 	

PTCA COMMENTS:
Temporary venous pacer wire was placed in the RV apex and pacing
was
done at 60 beats per minutes for complete heart block. Patient
went into
vfib with LCA injection. After CPR, cardioversion and pressors,
rythm
was esablished with AF and stable BP.  Patient was intubated in
this
process. 6F JR4 guide was used to engage the RCA then which
showed
totally occluded proximal RCA. which was crossed with prowater
wire. The
lesion in the prox RCA was first predilated with 2.0 X 8 mm Apex
balloon
at 12 atms at 12:10:19 PM re-establishing flow. Then we further
dilated
the long lesion in prox and mid RCA with 2.5 X 30 mm Sprinter Rx
balloon
at 12 atms. Then we stented the mid and proximal RCA with
overlapping
3.0 X 28mm and 3.0 X 18mm PROMUS [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5177**] at 10 and 12 atms.
Angio
shoed residual stenosis distal to the mid stent and we deployed
another
overlapping PROMUS 2.5 X 8 mm DES at 10 atms. We post dilated
the stents
with 3.0 X 21 nn NC balloon at 16 atms. Final angiogram showed
0%
residual stenosis, no dissection and normal flow. Angioseal
closure
device was used. Pacer wire was removed. Patient maintained
stable rythm
and was transferred to CCU.


TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 56 minutes.
Arterial time = 54 minutes.
Fluoro time = 17.2 minutes.
IRP dose = 283 mGy.
Contrast injected:
          Non-ionic low osmolar (isovue, optiray...), vol 160
ml, Indications - Renal
Premedications:
          Midazolam 3.5 mg IV
          Fentanyl 75 mcg IV
          ASA 325 mg P.O.
Anesthesia:
          1% Lidocaine subq.
Anticoagulation:
          Heparin 0 units IV
Other medication:
          Amiodarone bolus 300mg IV
          Dopamine drip 40mcg/kg/min IV
          Epinephrine bolus 1mg IV
          Etomidate 20mg IV
          Levophed 0.34mcg/kg/min IV
          Lidocaine 1% 5mL SQ
          Succinylcholine 100mg IV
Complications:
          Bradycardia
          Vf
Cardiac Cath Supplies Used:
          .014IN [**Doctor Last Name **], PROWATER 300CM
          .014IN [**Doctor Last Name **], PROWATER 300CM
          2.0MM [**Company **], BALLOON APEX FLEX OTW 12/1.5
          2.5MM [**Company **], SPRINTER 30MM
          3.0MM [**Company **], SPRINTER 20MM
          6FR CORDIS, JR 4 SH
          5FR BARD, PACING WIRE
          6FR [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL VIP
          - ALLEGIANCE, CUSTOM STERILE PACK
          - MERIT, LEFT HEART KIT
          - [**Doctor Last Name **], PRIORITY PACK 20/30
          3.0MM [**Company **], PROMUS OTW 28MM
          3.0MM [**Company **], PROMUS RX 18MM
          2.5MM [**Company **], PROMUS RX 08MM


COMMENTS:
1.  Selective coronary angiography of this right dominant system
demonstrated 2 vessel coronary artery disease.  The LMCA had no
angiographically apparent flow-limiting disease.  The LAD had <
50%
proximal and mid-vessel stenoses.  The LCx was small and had no
angiographically apparent flow-limiting disease.  The RCA was
totally
occluded in the proximal segment.
2.  Resting hemodynamics revealed seveverely elevated left- and
right-sided filling pressures with a mean PCWP of 30 mmHg and an
RVEDP
of 25 mmHg.  Systemic arteral pressures were normal on
vasopressor
support.  Cardiac output was preserved at 5.76 L/min with an
index of
3.47 L/min/m2, again on vasopressor support.
3. Successful PTCA/Stenting of proximal and mid RCA with three
overlapping PROMUS drug eluting stent prox to distal: 3.0 X 18
mm, 3.0 X
28 mm and 2.5 X 8 mm, the prox two stents were post dilated with
3.0 mm
NC balloon at high pressure (details below). Final angiogram
showed 0%
residual stenosis, no dissection and normal flow.

FINAL DIAGNOSIS:
1. One vessel significant coronary artery disease with RCA
occlusion.
2. Inferior STEMI and RV infarction.
3. Severely elevated left- and right-sided filling pressures.
4. Successful DES of proximal and mid RCA with three overlapping
PROMUS
stents.

- Portable TTE (Complete) Done [**2171-3-30**] at 11:33:12 AM
FINAL
Echocardiographic Measurements
Results 	Measurements 	Normal Range
Left Atrium - Long Axis Dimension: 	*4.2 cm 	<= 4.0 cm
Left Atrium - Four Chamber Length: 	*5.9 cm 	<= 5.2 cm
Right Atrium - Four Chamber Length: 	*6.0 cm 	<= 5.0 cm
    Left Ventricle - Septal Wall Thickness: 	*1.3 cm 	0.6 - 1.1
cm
    Left Ventricle - Inferolateral Thickness: 	*1.3 cm 	0.6 -
1.1 cm
    Left Ventricle - Diastolic Dimension: 	4.8 cm 	<= 5.6 cm
    Left Ventricle - Systolic Dimension: 	3.5 cm 	
    Left Ventricle - Fractional Shortening: 	*0.27 	>= 0.29
    Left Ventricle - Ejection Fraction: 	45% 	>= 55%
    Left Ventricle - Lateral Peak E': 	*0.07 m/s 	> 0.08 m/s
    Left Ventricle - Septal Peak E': 	*0.06 m/s 	> 0.08 m/s
    Left Ventricle - Ratio E/E': 	14 	< 15
Aorta - Sinus Level: 	3.1 cm 	<= 3.6 cm
Aorta - Ascending: 	2.2 cm 	<= 3.4 cm
Aorta - Arch: 	*3.3 cm 	<= 3.0 cm
    Aortic Valve - Peak Velocity: 	1.7 m/sec 	<= 2.0 m/sec
    Aortic Valve - Peak Gradient: 	7 mm Hg 	< 20 mm Hg
Mitral Valve - E Wave: 	0.9 m/sec 	
Mitral Valve - E Wave deceleration time: 	*104 ms 	140-250 ms
    TR Gradient (+ RA = PASP): 	21 mm Hg 	<= 25 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
Increased IVC diameter (>2.1cm) with <35% decrease during
respiration (estimated RA pressure (10-20mmHg).

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mildly depressed LVEF. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. RV function depressed.

AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Mildly dilated aortic
arch. Focal calcifications in aortic arch.

AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (area 1.2-1.9cm2).

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Mild [1+]
TR. Normal PA systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. Normal main PA. No Doppler evidence for
PDA

PERICARDIUM: No pericardial effusion.

Conclusions

The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %)
secondary to mild hypokinesis of the inferior septum and
posterior wall, and moderate hypokinesis of the inferior free
wall. The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic arch is mildly dilated. There are
focal calcifications in the aortic arch. There are three aortic
valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.

Compared with the findings of the prior report (images
unavailable for review) of [**2170-1-15**], evidence of
intercurrent inferior posterior and right ventricular infarction
now present, with relatively well-preserved overall left
ventricular ejection fraction and significant (but likely
reversible) right ventricular contractile dysfunction.

- CHEST (PORTABLE AP)	Study Date of [**2171-3-30**] 9:33 AM
FRONTAL CHEST RADIOGRAPH

The heart is mildly enlarged. There is no pneumothorax or
effusion. On
background chronic increased interstitial markings, there is
linear opacity at
the right lung base most likely representing atelectasis.
Aspiration cannot
be entirely excluded. There is linear left retrocardiac
atelectasis.
Degenerative changes of both glenohumeral joints are moderate in
extent

- ECG	Study Date of [**2171-3-29**]  11:16:08 AM
Atrial mechanism appears to be atrial fibrillation but
ventricular response is
regular suggesting independent junctional rhythm. ST-T wave
configuration
consistent with acute inferoposterior ischemic injury and
possible myocardial
infarction. Since the previous tracing of [**2170-1-9**] the
ventricular response is
now a regular bradycardia and ST-T wave abnormalities as
outlined are now
present.

- ECG	Study Date of [**2171-4-4**]  8:16:50 AM
Atrial fibrillation. Left axis deviation. Compared to tracing #1
the
T wave abnormalities in the inferior and lateral leads persist.
Clinical
correlation is suggested.

- CT HEAD W/O CONTRAST	Study Date of [**2171-3-30**] 11:06 AM
IMPRESSION:
No acute intracranial abnormality. If there is a high concern
for acute
infarction, an MRI with DWI can be performed for further
evaluation.

- PORTABLE ABDOMEN	Study Date of [**2171-3-31**] 1:52 PM
FINDINGS:
 Single portable supine abdominal radiograph demonstrates
scoliosis. There is
air present in non-dilated small bowel and colonic segments,
without frank
obstruction. This is a nonspecific small bowel gas pattern. Some
air is seen
within the rectum


Brief Hospital Course:
78 year old female s/p inferior STEMI with RV infarction and
observed v-fib arrest, now in slow atrial fibrillation,
extubated, off pressors.

# s/p Right ventricular/inferior STEMI + V-fib arrest: The
patient arrived with complaints of chest pain, and was noted on
EKG to have ST elevations in II, III, AVF, V3-5 and reciprocal
depressions in I, aVL, V1, V2 with inverted T waves in I, aVL,
V1, V2. She was taken to the cath lab, where her cath report
showed one vessel significant coronary artery disease with RCA
occlusion, an inferior STEMI and RV infarction, severely
elevated left and right sided filling pressures, in addition to
successful DES of proximal and mid RCA with three overlapping
PROMUS stents. However, her catheterization was notable for a
V-fib arrest which lasted for less than 1 minute. She was
shocked x2 and given epi x1 and amio x1 after which she resumed
her baseline rhythm. She was intubated, and was started on
pressors, and was transferred to the CCU. She was started on
aspirin, plavix, and atorvastatin; her metoprolol and ACE-I were
initally held in the setting of bardycardia and hypotension
requiring pressors; however, she eventually no longer required
pressors, and was started on metoprolol and lisinpril. Her ECHO
(for which the full report is in the results) showed mild
symmetric left ventricular hypertrophy, with left ventricular
systolic function mildly depressed (LVEF= 45 %) secondary to
mild hypokinesis of the inferior septum and posterior wall, and
moderate hypokinesis of the inferior free wall.

# Atrial fibrillation - The patient's known rhythm was atrial
fibrillation, and she was on coumadin for her afib on admission
as well. Her INRs were trended in the hospital, but her coumadin
was discontinued on [**2171-4-3**] secondary to a rise in her INR to 4,
likely secondary to changes in her warfarin dosing in-house from
4 days a week to daily. On the day of her discharge, she was
still supra-therapeutic at 3.7 (her INR had peaked around 6),
and so she was discharged and told NOT to take her coumadin
until she had had labs drawn with her PCP, [**Name10 (NameIs) 1023**] would then
instruct her if she should need to restart. Her coumadin was
also initally held on her admission secondary to concerns for
dysmetria, with concern for possible hemmoragic stroke; when CT
head was negative, her coumadin was restarted.

# Hypotension - The patient was initially treated in the CCU
with dopamine and levophed, and was subsequently able to be
weaned off these medication. Upon her discharge, she was no
longer hypotense, and was tolerating her metoprolol as well as
her lisonpril.

# Dysmetria - The patient on admission was noted to have
difficulty with finger-to-nose on her CCU exam. A CT head was
performed which was normal, and the patient's dysmetria
subsequently resolved. There was some concern initially that her
dysmetria might be secondary to alcohol withdrawal (the patient
endorsing drinking [**2-15**] drinks a night) but the patient did not
exhibit any signs of withdrawal, so her CIWA (which was order)
did not need to be used.

# Hypothyroidism: The patient in house was treated with a
slightly larger dose of her home levothyroxine at 137 mcg; at
home she had been taking 125 mcg. Her TSH in house was around 6,
but with a Free T4 on the low side of normal at 0.94, possibly
consistent with a sick euthyroid. As an outpatient, she should
have her TSH/Free T4 repeated to ensure that she is an
appropriate dose of levothyroxine.

# UTI: The patient has a known history of chronic UTIs. In
house, she had complained of some cystitis-type pain, for which
a U/A was performed and initially did not show any signs of
infection. however, during her hospitalization, she continued to
have dysuria; a repeat U/A and culture was performed indicating
an infection with E. Coli. She had initially been treated with
cefpodoxime, but her culture turned out to be resistent; given
her age and history of multiple urinary tract infections, she
was treated as a complicated UTI with Cipro for a 10 day course,
starting on [**2171-4-5**] to end on [**2171-4-14**].

# Urinary retention: Around the same time as the patient's
dysuria, the patient was noted to have some urinary retention as
well, with bladder scans showing 600 cc in her bladder at one
point, requiring straight catherterization. Urology was
consulted, and they reocmmended leaving foley for 5 days; she
was discharged with a foley and plans to follow-up with her PCP
or with her VNA for Foley removal. Her retention was felt likely
secondary to her UTI. Urology indicated that they would
follow-up if the PCP so desired.

# BRBPR: The patient one night noted bright red blood on the
toilet paper after having had a bowel movement. Hematocrits were
monitored and noted to be stable, and the BRBPR was felt to be
most consistent with hemmoroids; the patient was instructed to
contact her PCP if this started to bother her or if her bleeding
worsened.

# Diarrhea: In house the patient was noted to have some
diarrhea; C. Diff x 2 was sent off and was negative. The
patient's diarrhea resolved with loperamide.

Medications on Admission:
AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
CELECOXIB [CELEBREX] - 200 mg Capsule - 1 (One) Capsule(s) by
mouth once a day
LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet - 1 (One) Tablet(s)
by
mouth once a day and extra [**12-16**] tablet once weekly - No
Substitution
LISINOPRIL - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day
qhs
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 (One) Tablet(s) by
mouth
once weekly - No Substitution
WARFARIN [COUMADIN] - 5 mg Tablet - 1 Tablet(s) by mouth at
bedtime as directed by your primary care doctor, based on INR
readings

Medications - OTC
CALCIUM -  (OTC) - 500 mg Tablet - 2 (Two) Tablet(s) by mouth
twice a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] -  (OTC) - 1,000 unit
Tablet - 1 (One) Tablet(s) by mouth every other day
GLUCOSAMINE-CHONDROITIN -  (OTC) - Dosage uncertain

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).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
6. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
9. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
10. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
11. Glucosamine Chondroitin MaxStr  Oral
12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
13. Outpatient Lab Work
Please check INR on Saturday [**4-6**] with results to Dr. [**First Name (STitle) **] at
[**Telephone/Fax (1) 250**]


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Right Ventiricular STEMI
Ventricular Fibrillation Arrest
Atrial fibrillation on warfarin
Dysmetria after arrest
Gastroenteritis with diarrhea
Urinary Retention


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You had a heart attack and needed a cardiac catheterization.
Three drug eluting stents were placed in your right coronary
artery to fix a blockage. These stents will stay in place from
now on and you will need to take aspirin and plavix every day
for at least one year and possibly longer to prevent the stents
from clotting off and causing another heart attack. Do not stop
taking aspirin/plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **].
You also had some diarrhea that appeared to be from stress and
laxative use, there was no evidence of infection. You should
follow a BRAT diet and avoid dairy products. You can use imodium
after each diarrhea episode. You had a small amount of blood
from your rectum, probably from internal hemorrhoids or
irritation to the colon. You are not losing significant amounts
of blood but please call Dr. [**First Name (STitle) **] if this worsens.
You had urinary retention from bladder distention after the
Foley catheter was removed, there was also an infection in your
urine. The foley was replaced and can be removed on Tuesday at
Dr.[**Name (NI) 14065**] office. You will need to take antibiotics for 7
days.
.
We made the following changes to your medicines:
1. STart taking aspirin and Plavix daily to prevent the stent
from clotting off
2. Start taking ATorvastatin to lower your cholesterol
3. Start taking Ciprofloxacin to treat your urinary tract
infection
4. Increase Lisinopril to lower your blood pressure and help
your heart pump better
5. Start taking Metoprolol to lower your heart rate instead of
Atenolol
6. STOP taking Amlodipine, Celebrex and ATenolol.
7. Stop taking coumadin for now. Your INR was 3.7 today and we
expect it will be lower tomorrow. The VNA will send an INR
tomorrow and Dr.[**Name (NI) 14065**] office will tell you how much coumadin
to take.

Followup Instructions:
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2171-4-23**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: TUESDAY [**2171-4-23**] at 10:00 AM
With:  BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: FRIDAY [**2171-5-31**] at 10:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: TUESDAY [**2171-4-9**] at 9:00 AM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: THURSDAY [**2171-5-9**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Ventricular fibrillation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Lack of coordination,Unspecified hemorrhoids with other complication,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Other and unspecified noninfectious gastroenteritis and colitis,Osteoporosis, unspecified,Personal history, urinary (tract) infection,Long-term (current) use of anticoagulants,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}


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: Chest pain

PRESENT ILLNESS: This is a 78 year old female with history of hypertension,
hypothyroidism presenting with chest pain over the last week.
The chest pain had been intermittent until this morning of
admission around 10 AM while driving back from the grocery
store, when it became constant. She denied shortness of breath,
nausea, vomiting, diaphoresis at the time. She presented to the
ED, vital signs were HR:46 BP:129/70 Resp:18 O(2)Sat:100% 2L NC.
She had an EKG that showed rate 47, atrial fibrillation, axis
slight right axis deviation, ST elevations in II, III, AVF, V3-5
and reciprocal depressions in I, aVL, V1, V2 with inverted T
waves in I, aVL, V1, V2; ST segments resolved in precordial
leads; ? q waves in lead V1. A right sided EKG showed signifacnt
ST elevations in V3-6. Patient was taken to the cath lab and had
a V-fib arrest for less than 1 minute. She was shocked x2 and
given epi x1 and amio x1 after which she resumed her baseline
rhythm of atrial fibrillation with slow ventricular rates. At
this time she was also started on levophed and dopamine for MAPs
< 60s. She was transferred to the CCU; vitals at time of
transfer showed HRs of 70s in atrial fibrillation, BP of 115/70,
intubated, but responsive to instructions.

MEDICAL HISTORY: 1. Hypothyroidism diagnoised more than 30 years ago
2. Atrial fibrillation
3. Hypertension
4. Frequent UTIs
5. Osteoarthritis
6. IBS

MEDICATION ON ADMISSION: AMLODIPINE [NORVASC] - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
CELECOXIB [CELEBREX] - 200 mg Capsule - 1 (One) Capsule(s) by
mouth once a day
LEVOTHYROXINE [SYNTHROID] - 125 mcg Tablet - 1 (One) Tablet(s)
by
mouth once a day and extra [**12-16**] tablet once weekly - No
Substitution
LISINOPRIL - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day
qhs
RISEDRONATE [ACTONEL] - 35 mg Tablet - 1 (One) Tablet(s) by
mouth
once weekly - No Substitution
WARFARIN [COUMADIN] - 5 mg Tablet - 1 Tablet(s) by mouth at
bedtime as directed by your primary care doctor, based on INR
readings

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Strawberry

PHYSICAL EXAM: GEN: Caucasian female, intubated, off sedation able to follow
instructions
Neuro: Positive for dysmetria on cerebellar testing, difficulty
with finger to nose
CARDIAC: Nl s1/s2, RRR no murmurs appreciable
RESP: Lungs clear bilaterally, no rales appreciable
ABD: Soft, nontender, nondistended, no hepatosplenomegaly, no
masses palpable
Ext: soft, absent pulses in right lower extremity, left lower
extremity 1+ pulses distally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Non-contributory 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Ventricular fibrillation,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Atrioventricular block, complete,Coronary atherosclerosis of native coronary artery,Hypotension, unspecified,Lack of coordination,Unspecified hemorrhoids with other complication,Retention of urine, unspecified,Unspecified acquired hypothyroidism,Other and unspecified noninfectious gastroenteritis and colitis,Osteoporosis, unspecified,Personal history, urinary (tract) infection,Long-term (current) use of anticoagulants,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}
