CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: 84F h/o MI in [**2086**] and CVA [**2099**], on Coumadin FOR AFIB, denies
CABG or stents, c/o 1 hr of chest tightness, nausea,
diaphoresis, onset while at rest watching TV. Followed by Mark
[**Doctor Last Name **] at [**Location (un) **]. In ED had inferior STEMI with 2>3 STE in
inferior leads. She got ASA and a Heparin bolus. INR was >3 so
no gtt started. She was not given plavix prior to procedure.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: CAD
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-  Knwon MI in [**2088**]
-  CVA
- Afib on coumadin
-

MEDICATION ON ADMISSION: Warfarin 3.75-7mg
Calcium 600 D
HCTZ 25 mg QD
Lipitor 10mg QD
Immodium PRN
Maalox 2 tsp QHS
Metoprolol 50mg QD
MVI
Probiotics
Tylenol 500mg [**Hospital1 **] PRN
-

ALLERGIES: Codeine

PHYSICAL EXAM: VS: 120 97/70 RR18 02 SAT 100%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Tobacco history: Quit smokign 21 years ago
- ETOH: occasional glass of wine
- Illicit drugs: none
Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Drug-induced delirium,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Other iatrogenic hypotension,Heart disease, unspecified,Unspecified essential hypertension,Other specified retention of urine,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Anticoagulants causing adverse effects in therapeutic use,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
AMI inferior wall, init,Cardiogenic shock,Prim cardiomyopathy NEC,Parox ventric tachycard,Drug-induced delirium,Long-term use anticoagul,Crnry athrscl natve vssl,Abnrml coagultion prfile,Iatrogenc hypotnsion NEC,Heart disease NOS,Hypertension NOS,Oth spcf retention urine,Adv eff parasympatholytc,Hx TIA/stroke w/o resid,Adv eff anticoagulants,Abn react-cardiac cath
Admission Date:  [**2109-3-31**]              Discharge Date:   [**2109-4-5**]

Date of Birth:  [**2026-11-6**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
cath

History of Present Illness:
84F h/o MI in [**2086**] and CVA [**2099**], on Coumadin FOR AFIB, denies
CABG or stents, c/o 1 hr of chest tightness, nausea,
diaphoresis, onset while at rest watching TV. Followed by Mark
[**Doctor Last Name **] at [**Location (un) **]. In ED had inferior STEMI with 2>3 STE in
inferior leads. She got ASA and a Heparin bolus. INR was >3 so
no gtt started. She was not given plavix prior to procedure.

She was taken to the cath lab where she was found to have
90-100% mid RCA occlusion. The wire was delpoyed across the
lesion but due to her INR of >3 and fragile appearing [**Last Name (un) 12599**]
she was not felt to be a canditate for stenting. She underwent
baloon angioplasty.
.
Following proceure, As radial T band was being remove she
vagaled and had SBP drop to 50's with HR in the 150's. Was given
1-2 mg of atropine, started on dopamine. Systolics rose to the
80's. She was then given 10mg IV diltiazem followed by 15mg IV
metoprolol with control of her HR to the 130's and SBP to 100's.
She arrives ont he floor on 10 of dopa.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: CAD
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-  Knwon MI in [**2088**]
-  CVA
- Afib on coumadin
-

Social History:
- Tobacco history: Quit smokign 21 years ago
- ETOH: occasional glass of wine
- Illicit drugs: none

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
VS: 120 97/70 RR18 02 SAT 100%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with no JVP elevation
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
.
Exam at discharge:
Vitals T 98.4 BP 125-156/76-86 HR 85-100RR 18 O2 94RA
I/O:
Tele: AF, rate 90's-low 100's no VEA
Weight: 58.3(58.6)
.
General Appearance: NAD, sitting in chair
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: irregularly irregular (S1: Normal), JVP 12cm
H2O, no murmurs, rubs or gallops
Respiratory / Chest: CTAB
Abdominal: Soft, Non-tender
Extremities: right LE with 1+, LLE nl.
Neurologic: Oriented to self, [**Hospital1 18**], Month, year, good attention

Pertinent Results:
ADMISSION LABS:
[**2109-3-31**] 06:15PM BLOOD WBC-6.6 RBC-3.59* Hgb-12.1 Hct-36.5
MCV-102* MCH-33.8* MCHC-33.3 RDW-12.6 Plt Ct-219
[**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0*
[**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144
K-3.0* Cl-105 HCO3-26 AnGap-16
[**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01
[**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54*
[**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65*
[**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5*
[**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123
[**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52
[**2109-3-31**] 06:22PM BLOOD Glucose-109* Lactate-2.3* Na-141 K-3.3
Cl-102 calHCO3-28

PERTINENT INTERVAL LABS:
[**2109-3-31**] 07:00PM BLOOD WBC-7.0 RBC-3.35* Hgb-11.0* Hct-33.1*
MCV-99* MCH-32.9* MCHC-33.3 RDW-12.7 Plt Ct-194
[**2109-4-1**] 12:54AM BLOOD Hct-32.2* Plt Ct-199
[**2109-4-1**] 05:11AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.9* Hct-33.4*
MCV-100* MCH-32.5* MCHC-32.6 RDW-12.8 Plt Ct-203
[**2109-4-2**] 01:31AM BLOOD WBC-8.5 RBC-3.13* Hgb-10.4* Hct-31.0*
MCV-99* MCH-33.3* MCHC-33.6 RDW-12.9 Plt Ct-182
[**2109-4-3**] 06:29AM BLOOD WBC-6.4 RBC-3.12* Hgb-10.2* Hct-31.6*
MCV-101* MCH-32.7* MCHC-32.3 RDW-13.4 Plt Ct-179
[**2109-3-31**] 07:00PM BLOOD PT-40.4* PTT->150 INR(PT)-4.0*
[**2109-4-1**] 05:11AM BLOOD PT-29.3* PTT-41.3* INR(PT)-2.8*
[**2109-4-2**] 12:31PM BLOOD PT-38.9* INR(PT)-3.8*
[**2109-4-3**] 06:29AM BLOOD PT-29.0* PTT-38.1* INR(PT)-2.8*
[**2109-3-31**] 07:00PM BLOOD Glucose-113* UreaN-17 Creat-1.0 Na-144
K-3.0* Cl-105 HCO3-26 AnGap-16
[**2109-4-1**] 05:11AM BLOOD Glucose-131* UreaN-18 Creat-1.1 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2109-4-2**] 01:31AM BLOOD Glucose-118* UreaN-22* Creat-1.2* Na-141
K-3.6 Cl-104 HCO3-22 AnGap-19
[**2109-4-3**] 06:29AM BLOOD Glucose-78 UreaN-21* Creat-1.0 Na-142
K-3.5 Cl-107 HCO3-25 AnGap-14
[**2109-4-1**] 12:54AM BLOOD CK(CPK)-734*
[**2109-4-1**] 05:11AM BLOOD CK(CPK)-788*
[**2109-4-1**] 01:22PM BLOOD CK(CPK)-633*
[**2109-4-2**] 01:31AM BLOOD CK(CPK)-603*
[**2109-4-3**] 06:29AM BLOOD ALT-41* AST-67* AlkPhos-41 TotBili-0.7
[**2109-3-31**] 06:15PM BLOOD Lipase-59
[**2109-3-31**] 06:15PM BLOOD cTropnT-<0.01
[**2109-4-1**] 12:54AM BLOOD CK-MB-88* MB Indx-12.0* cTropnT-3.54*
[**2109-4-1**] 05:11AM BLOOD CK-MB-87* MB Indx-11.0* cTropnT-3.65*
[**2109-4-1**] 01:22PM BLOOD CK-MB-48* MB Indx-7.6* cTropnT-2.35*
[**2109-4-2**] 01:31AM BLOOD CK-MB-25* MB Indx-4.1 cTropnT-1.88*
[**2109-4-1**] 12:54AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.5*
[**2109-4-2**] 01:31AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.8
[**2109-4-3**] 06:29AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1
[**2109-3-31**] 07:00PM BLOOD %HbA1c-5.9 eAG-123
[**2109-3-31**] 07:00PM BLOOD Triglyc-81 HDL-52 CHOL/HD-2.3 LDLcalc-52
STUDIES:
ECG ([**3-31**]):
Sinus rhythm. Right bundle-branch block. Inferior ST segment
elevation
consistent with an acute inferior myocardial infarction and
probable lateral extension with slight ST segment elevation in
leads V5-V6. There is reciprocal ST segment depression in leads
I, aVL and V1-V2. No previous tracing available for comparison.


Cardiac Cath ([**3-31**]):
COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated one-vessel coronary artery disease.  The LMCA, LAD,
and LCx
had minimal disease but were free of angiographically-apparent
flow-limiting stenoses.  The mid-RCA was subtotally occluded.
2) After the mid-RCA angioplasty, she began complaining of
nausea and
dizziness and was noted to have a noninvasive sBP in the high
50s.  The
transducer was connected to the right radial arterial sheath
sidearm,
with blunted pressure recordings.  Noninvasive readings were
consistently below sBP 70.  She was given 2 mg atropine for
presumed
vagal reaction, and started on IV fluids and dopamine, up to 20
mcg/kg/min.  A right common femoral arterial sheath was placed
in
preparation for possible IABP placement.  However, her sBPs were
then
noted to be in the 80s-90s.  At that time, her heart rates were
in the
140s-150s (transiently as high as 200) and appeared to be atrial

fibrillation; she was then given 15mg IV metoprolol with
resulting heart
rates in the 120s and stable sBPs in the 100s.  The RCFA sheath
was
manually pulled and a TR band was applied to the RRA site.  She
was
transported to the CCU in stable condition.
ADDENDUM: PCI COMMENTS:
Initial angiography revealed a subtotally occluded RCA. We
planned to
treat this using PTCA. A 6 Fr JR5 guiding catheter provided
reasonable
support throughout the procedure. Chronic Warfarin therapy with
known
INR of 3.2 48 hours prior. A Prowater wire was successfully
advanced
across the target lesion and positioned in the distal vessel. An
Apex
2.0 x 8 mm balloon was used to pre-dilate the occlusion,
restoring flow
to the vessel. Attempts were made to deliver a Mini-Vision 2.0 x
12 mm
and then a 2.0 x 8 mm stent, however we were unable to advance
these
across the lesion. Final angiography showed TIMI 3 flow within
the
vessel and no apparent dissection. It was elected to stop with
conventional balloon angioplasty given her elevated INR. Post
angioplasty hemodynamic course as documented above. Hemostasis
achieved
at right radial arterial access site using TR band.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease status post primary
balloon
angioplasty of the mid-RCA stenosis.
2. Vagal reaction and hypotension requiring pressors and fluids.

.
ECG ([**2109-3-31**]): rate 84, Baseline artifact makes P wave morphology
difficult. This could be sinus rhythm with premature atrial
contractions and ventricular premature beats versus atrial
fibrillation with ventricular premature beats. Right
bundle-branch block. Inferior and lateral ST segment elevation
consistent with an acute inferior myocardial infarction.
Compared to tracing #1 baseline artifact is more pronounced.
.
ECG [**2109-3-31**]: rate 133. Probable atrial fibrillation with a rapid
ventricular response and baseline artifact. Right bundle-branch
block. Left anterior fascicular block. Q waves in leads III and
aVF consistent with an inferior myocardial infarction which is
probably acute. Compared to tracing #2 the inferior and lateral
ST segment elevation is less pronouced. Q waves are more
apparent in leads III and aVF. TRACING #3
.
ECG [**2109-3-31**]: rate 126. Possible atrial flutter with variable
block. Right bundle-branch block  with left anterior fascicular
block. Slight ST segment elevation in leads III and aVF with Q
waves suggesting evolution of an inferior myocardial infarction.
Premature ventricular contraction is also present. Lateral ST-T
wave changes consistent with ongoing ischemia. Compared to
tracing #3 atrial flutter may be present. The ventricular
premature beat is new.
.
ECG [**2109-3-31**]: rate 123. Probable atrial fibrillation with a rapid
ventricular response. Right bundle-branch block with left
anterior fascicular block. Inferior myocardial infarction which
is evolving. ST-T wave changes suggest ongoing ischemia.
Compared to tracing #5 the ventricular rate is slower.
.
ECG [**2109-4-1**]: rate 86. Atrial flutter at an atrial rate of about
300 with variable block. Right bundle-branch block with left
anterior fascicular block. Inferior myocardial infarction with
inferior T wave inversions suggesting an evolving inferior
myocardial infarction. Non-specific T wave flattening in leads
V4-V6. Compared to tracing #6 the ventricular rate is slower.
The ST segment depression in leads V1-V2 is less pronounced.
.
ECHO [**2109-4-1**]: The left atrium is elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is 5-10 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the basal half
of the inferior septum, inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 35 %). The right
ventricular cavity is mildly dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-26**]+) mitral regurgitation is seen.
Severe [4+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
moderate regional systolic dysfunction c/w CAD. Severe tricuspid
regurgitation. Pulmonary artery hypertension. Mild-moderate
mitral regurgitation.

Labs on Discharge:

[**2109-4-5**] 06:55AM BLOOD WBC-6.3 RBC-3.12* Hgb-10.2* Hct-31.4*
MCV-101* MCH-32.6* MCHC-32.4 RDW-13.6 Plt Ct-198
[**2109-4-5**] 06:55AM BLOOD PT-26.2* INR(PT)-2.5*
[**2109-4-5**] 06:55AM BLOOD UreaN-19 Creat-0.9 Na-144 K-3.8 Cl-108
HCO3-30 AnGap-10
[**2109-4-4**] 06:56AM BLOOD Calcium-8.4 Phos-2.6* Mg-1.9

Brief Hospital Course:
Brief Clinical Summary:
Ms. [**Known lastname **] is an 82 year old woman with history of CAD, Afib on
coumadin and CVA who presented with inferior STEMI secondary to
RCA occlusion now s/p percutaneous balloon angioplasty with
immediate post procedural course complicated by hypotension and
tachycardia initially requiring pressors, hospitalization
complicated by delirium.

Issues:
# Inferior STEMI:
Because patient presented with supratherapeutic INR, decision
was made not to commit patient to plavix with PCI, so she
underwent POBA of the RCA.  She was chest pain free with
resolution of ST changes after intervention. She was initially
hypotensive and bradycardic on presentation, requiring dopamine
for support which was soon weaned off.  She also received a dose
of atropine on the night of presentation, after which she became
more delirious.  She was continued on aspirin, beta blocker.
Atorvastatin dose was increased to 80mg daily. Lisinopril 2.5mg
was started prior to discharge. TTE showed EF of 35%, symmetric
LVH with moderate regional systolic dysfunction, severe TR,
moderate mitral regurgitation, and RV failure. Hemoglobin A1c
was 5.9% consistent with prediabetes.  Lipid panel showed HDL
54, LDL 47 and trigl 108. The patient has been arranged with
cardiac follow-up.

# Acute Systolic Dysfunction: EF 35% on ECHO. No signs of CHF
during her hospital stay. Her discharge weight is 128 pounds.
She will require daiy weights with the consideration of starting
a diuretic if her weight increases or she shows signs of CHF. An
ECHO should be scheduled in [**3-1**] weeks to assess LV function.

# Delirium:
ICU course was complicated by significant delirium which quickly
resolved on the floor.  She was given several doses of
olanzapine and quetiapine in the ICU in efforts to restore her
sleep-wake cycle.

# Afib with RVR:
She remained in atrial fibrillation throughout hospitalization.
CHADS score is 4. Presented with supratherapeutic INR, so
warfarin was initially held, then restarted prior to discharge.
She was continued on metoprolol.

# Hypertension
Home antihypertensives were initially held in the setting of
hypotension.  When hemodynamically stable, she was restarted on
metoprolol in setting of atrial fibrillation, and she was
started on low dose lisinopril.  Her metoprolol was increased to
150 of succinate once per day.  Home HCTZ was discontinued.

# Code Status was FULL CODE during this hospitalization
# Husband:  [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 18277**].

Transitional Issues:
1. cardiology f/u
2. uptitrate lisinopril as tolerated
3. uptitrate metoprolol as tolerated

Medications on Admission:
Warfarin 3.75-7mg
Calcium 600 D
HCTZ 25 mg QD
Lipitor 10mg QD
Immodium PRN
Maalox 2 tsp QHS
Metoprolol 50mg QD
MVI
Probiotics
Tylenol 500mg [**Hospital1 **] PRN
-

Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
[**Hospital1 **]:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
2. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
please adjust dose as instructed by your doctor.
[**Last Name (Titles) **]:*90 Tablet(s)* Refills:*2*
3. Calcium 500 + D  Oral
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
7. immodium  Sig: One (1)   once a day as needed for diarrhea.
8. Maalox RS  Oral
9. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
10. probiotics  Sig: One (1)   once a day.
11. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] at [**Location (un) 620**]

Discharge Diagnosis:
ST Elevation Myocardial Infarction
Delirium
Hypertension
Tachycardia


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


Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you had a heart
attack. We started you on new medications to help protect your
heart. You had some delirium (confusion) in the hospital, which
is now improved.

The following changes were made to your medications:
- STOP Hydrochlorothiazide
- DECREASE Warfarin to 3mg daily and adjust your dose as
instructed by your doctor
- INCREASE Lipitor to 80mg daily to lower your cholesterol
- START Aspirin 325mg daily to prevent blood clots
- INCREASE Metoprolol Succinate to 150mg daily to slow your
heart rate
- START lisinopril 2.5mg daily

It was a pleasure taking care of you, we wish you all the best!

Followup Instructions:
Name: MARK [**Name Initial (MD) **] [**Name8 (MD) **],MD
Location: [**Hospital3 **] CARDIOLOGISTS
When: Tuesday [**4-9**] at 1pm
Address: [**2109**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 18278**]



Completed by:[**2109-4-5**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Drug-induced delirium,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Other iatrogenic hypotension,Heart disease, unspecified,Unspecified essential hypertension,Other specified retention of urine,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Anticoagulants causing adverse effects in therapeutic use,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: STEMI

PRESENT ILLNESS: 84F h/o MI in [**2086**] and CVA [**2099**], on Coumadin FOR AFIB, denies
CABG or stents, c/o 1 hr of chest tightness, nausea,
diaphoresis, onset while at rest watching TV. Followed by Mark
[**Doctor Last Name **] at [**Location (un) **]. In ED had inferior STEMI with 2>3 STE in
inferior leads. She got ASA and a Heparin bolus. INR was >3 so
no gtt started. She was not given plavix prior to procedure.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: CAD
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-  Knwon MI in [**2088**]
-  CVA
- Afib on coumadin
-

MEDICATION ON ADMISSION: Warfarin 3.75-7mg
Calcium 600 D
HCTZ 25 mg QD
Lipitor 10mg QD
Immodium PRN
Maalox 2 tsp QHS
Metoprolol 50mg QD
MVI
Probiotics
Tylenol 500mg [**Hospital1 **] PRN
-

ALLERGIES: Codeine

PHYSICAL EXAM: VS: 120 97/70 RR18 02 SAT 100%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Tobacco history: Quit smokign 21 years ago
- ETOH: occasional glass of wine
- Illicit drugs: none 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Other primary cardiomyopathies,Paroxysmal ventricular tachycardia,Drug-induced delirium,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Other iatrogenic hypotension,Heart disease, unspecified,Unspecified essential hypertension,Other specified retention of urine,Parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics causing adverse effects in therapeutic use,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Anticoagulants causing adverse effects in therapeutic use,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
