CHIEF COMPLAINT: elective right carotid angiography and possible stenting

PRESENT ILLNESS: 78 yo female with known coronary artery and peripheral [**First Name3 (LF) 1106**]
disease, status post AMI and LAD, LCX and left carotid
revascularizations in [**Month (only) 205**], now referred for right carotid
angiography and possible revascularization.
.
The patient states that she had been in her usual state of
health, and is now here for elective
angiography/revascularization. In [**8-12**], the patient had an
anterior STEMI and was taken to the cath lab at [**Hospital1 **], where
she was found to have an 80%
proximal LAD stenosis, an 80-90% LCX stenosis, an 80% RCA
stenosis and a 60-70% ramus stenosis. Given her 3 vessel
disease.
she was transferred to [**Hospital1 18**] for evaluation by CT surgery for
possible CABG A carotid ultrasound was done as part of her
evaluation and she was found to have 80-90% bilateral carotid
stenosis, making her a poor surgical candidate. She was also
found to have poor conduits due to prior vein stripping. She was

MEDICAL HISTORY: CARDIAC HISTORY:
Percutaneous coronary intervention, in anatomy as follows:
stenting of proximal LAD with a 2.5 x 18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
 8mm Cypher to the OM1.
A 3.5 x 18mm Cypher DES was also placed to the mid RCA.
left internal carotid placement of a [**7-14**] x 30mm acculink stent.

MEDICATION ON ADMISSION: Aspirin 325mg daily in the am
Plavix 75mg daily in the am
Atenolol 25mg daily in the am
Triamterene/hctz 37.5/25mg daily in the am
Lipitor 80mg [**2-7**] tablet daily in the pm
Xalatan 0.005% 1 gtt OU qHS
Cosupt 1gtt OU [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.3, BP 102/39 , HR 58 , RR 20, O2 96% on RA
Gen: elderly obese female in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 3 mm, left pupil 1
mm, non reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple with JVP 6-8 cm
CV: RRR, normal S1, S2. No S4, no S3.
Chest:Resp were unlabored, no accessory muscle use. Clear
anteriorly. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND. No abdominial bruits.
Ext: 1+ BLE edema, chronic venous stasis changes. No femoral
bruits. right groin central line in place, no tenderness, no
hematoma, no thrill.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP, 2+ PT
[**Name (NI) 2325**]: Carotid 2+ with bruit; 1+ DP, 2+ PT

FAMILY HISTORY: Her Father had a heart attack at age 64. There is no family
history of premature coronary artery disease or sudden death.

SOCIAL HISTORY: Married, lives at home with her husband. Retired. Daughter,
[**Name (NI) 1785**] is very involved in patient??????s care The patient does not
drink any alcohol. She denies history of drug use. She currently
does not smoke; but has a 40+ pack year history. Currently has
[**Location (un) 1110**] VNA
Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Peripheral vascular disease, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Percutaneous transluminal coronary angioplasty status,Personal history of other diseases of digestive system,Morbid obesity,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Macular degeneration (senile), unspecified,Old myocardial infarction,Examination of participant in clinical trial
Ocl crtd art wo infrct,Crnry athrscl natve vssl,Periph vascular dis NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Status-post ptca,Prsnl hst ot spf dgst ds,Morbid obesity,Osteoarthros NOS-unspec,Macular degeneration NOS,Old myocardial infarct,Exam-clincal trial
Admission Date:  [**2113-12-4**]              Discharge Date:   [**2113-12-5**]

Date of Birth:  [**2035-6-1**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
elective right carotid angiography and possible stenting

Major Surgical or Invasive Procedure:
Carotid angiography and stent placement


History of Present Illness:
78 yo female with known coronary artery and peripheral [**First Name3 (LF) 1106**]
disease, status post AMI and LAD, LCX and left carotid
revascularizations in [**Month (only) 205**], now referred for right carotid
angiography and possible revascularization.
.
The patient states that she had been in her usual state of
health, and is now here for elective
angiography/revascularization. In [**8-12**], the patient had an
anterior STEMI and was taken to the cath lab at [**Hospital1 **], where
she was found to have an 80%
proximal LAD stenosis, an 80-90% LCX stenosis, an 80% RCA
stenosis and a 60-70% ramus stenosis. Given her 3 vessel
disease.
she was transferred to [**Hospital1 18**] for evaluation by CT surgery for
possible CABG A carotid ultrasound was done as part of her
evaluation and she was found to have 80-90% bilateral carotid
stenosis, making her a poor surgical candidate. She was also
found to have poor conduits due to prior vein stripping. She was

therefore referred for percutaneous intervention.
.
On [**2113-8-23**], she returned to the cath lab for a successful
thrombectomy, angioplasty and stenting of her proximal LAD with
a
2.5 x 18mm Cypher DES. Carotid angiography revealed bilateral
high grade carotid stenosis. She had a 90% Mid LCX stenosis and
a
60% proximal Ramus stenosis that were not intervened upon at
that
time. (RCA disease not reported in cath report)
.
She returned again to the cath lab on [**2113-8-24**] for carotid
angiography. This revealed a 99 % left internal carotid artery
stenosis and a 60% right internal carotid artery stenosis. She
was also found to have an 80% right subclavian artery stenosis.

She underwent a successful left internal carotid intervention
with placement of a [**7-14**] x 30mm acculink stent. A 6F angioseal
was
placed to her right femoral artery at that time.
.
The patient??????s post procedure course was complicated by a GI
bleed
with a hct drop from 28 to 23.5. She was treated with 2 units of

PRBC??????s. A colonoscopy was significant for rectal polyps,
external
hemorrhoids and diverticulosis of the entire colon.
.
The patient returned again to the cath lab on [**2113-11-1**] and had a

3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x

8mm Cypher to the OM1. A 3.5 x 18mm Cypher DES was also placed
to the mid RCA.
.
The patient was admitted to the CCU after her angiography and
revascularization of her right cartoid. She had a 7-10x30mm
Acculink
stent posted with a 4.5mm balloon to 16atms. Excellent result
with
normal flow down vessel and 10% residual. Post procedure; the
patient is doing well. She is without complaints. She denies
chest pain, shortness of breath, weakness or dumbness in the
extremeties, dysarthria, or visual changes. The patient was
already blind in her left eye. Her SBPs have been in the
90s-110s.
.
On review of symptoms, she denies any prior history of stroke,
TIA, amurosis fugax, deep venous thrombosis, pulmonary embolism,
cough, hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies exertional buttock or calf
pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope. Of note, the patient reports chronic LE edema for
which she is taking a "water pill."


Past Medical History:
CARDIAC HISTORY:
Percutaneous coronary intervention, in anatomy as follows:
stenting of proximal LAD with a 2.5 x 18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
 8mm Cypher to the OM1.
A 3.5 x 18mm Cypher DES was also placed to the mid RCA.
left internal carotid placement of a [**7-14**] x 30mm acculink stent.

.
PAST MEDICAL HISTORY:
CAD s/p anterior MI/LAD stent [**8-12**]
GI bleed [**8-12**] post LAD and carotid intervention
Left carotid artery stenosis, s/p stent [**8-12**]
Hypertension
Hyperlipidemia
Macular degeneration-Left Eye Blindness
Varicose veins s/p remote bilateral lower extremity vein
stripping
Morbid obesity
Degenerative joint disease
Remote appendectomy
Remote hysterectomy


Social History:
Married, lives at home with her husband. Retired. Daughter,
[**Name (NI) 1785**] is very involved in patient??????s care The patient does not
drink any alcohol. She denies history of drug use. She currently
does not smoke; but has a 40+ pack year history. Currently has
[**Location (un) 1110**] VNA

Family History:
Her Father had a heart attack at age 64. There is no family
history of premature coronary artery disease or sudden death.

Physical Exam:
VS: T 97.3, BP 102/39 , HR 58 , RR 20, O2 96% on RA
Gen: elderly obese female in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 3 mm, left pupil 1
mm, non reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple with JVP 6-8 cm
CV: RRR, normal S1, S2. No S4, no S3.
Chest:Resp were unlabored, no accessory muscle use. Clear
anteriorly. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND. No abdominial bruits.
Ext: 1+ BLE edema, chronic venous stasis changes. No femoral
bruits. right groin central line in place, no tenderness, no
hematoma, no thrill.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP, 2+ PT
[**Name (NI) 2325**]: Carotid 2+ with bruit; 1+ DP, 2+ PT


Pertinent Results:
[**2113-12-5**] 05:43AM BLOOD WBC-5.5 RBC-3.53* Hgb-10.4* Hct-31.8*
MCV-90 MCH-29.4 MCHC-32.5 RDW-13.9 Plt Ct-173
[**2113-12-5**] 05:43AM BLOOD Plt Ct-173
[**2113-12-5**] 05:43AM BLOOD Glucose-86 UreaN-26* Creat-0.9 Na-139
K-4.1 Cl-112* HCO3-23 AnGap-8
[**2113-12-5**] 05:43AM BLOOD CK(CPK)-77
[**2113-12-4**] 08:51PM BLOOD CK(CPK)-61

STUDIES:
CATHETERIZATION:
PTCA COMMENTS:     Initial angiography revealed a 90% focal
stenosis of
the right internal carotid artery. We planned to perform
PTCA/stenting
to this lesion. Heparin was commenced prophylactically. A 6F
Shuttle
sheath was inserted into the right common carotid. A 6.5mm
AccuNet
filter was deployed distally. The lesion was predilated with a
2.5mm
balloon and then stented with a [**8-15**] x30mm Acculink stent posted
with a
4.5mm balloon to 16atms. Excellent result with 10% residual and
normal
flow down vessel. The filter was retrieved without difficulty
and no
evidence of embolic debris. The patient was stable at end of
procedure
with no neurlogical symptoms.
.
COMMENTS:
1. The LCCA is normal. The previous left internal carotid stent
is
patent.
2. The RCCA is normal. The right ICA has a focal 90% lesion with

post-stenotic dilatation. The ICA fills the ipsilateral MCA/ACA
and
cross fills the contralaterl ACA.
3. Successful PTA and stenting of right ICA with a 7-10x30mm
Acculink
stent posted with a 4.5mm balloon to 16atms. Excellent result
with
normal flow down vessel and 10% residual. Patient left cathlab
in stable
condition with no neurological sequelae.


FINAL DIAGNOSIS:
1. Focal 90% stenosis of right ICA
2. Patent left ICA stent
3. Successful PTA and stenting of right ICA with 7-10x30mm
stent.


Brief Hospital Course:
78 yo female with CAD, peripheral arterial disease,
hypertension, and hyperlipidemia presents for elective right
carotid angiography and revascularization now s/p stent
placement of R carotid
.
# s/p R carotid stenting: The patient had 7-10x30mm Acculink
stent posted with a 4.5mm balloon to 16atms in the right
carotid.  Dr. [**First Name (STitle) **] had an SBP goal for the patient of 100-180.
 Her SBP tended to stay in the low 100s, but occasionally dipped
down into the low 90s and upper 80s.  With normal saline boluses
of 250-500 cc, the patient maintained her SBP>100.  She had no
neurological deficits noted on exam.  She had no change in
mental status.  At discharge, she was able to ambulate without
difficulty at her baseline level.  She tolerated the procedure
well and there were no immediate complications.  She will
followup with Dr. [**First Name (STitle) **] in one month, and follow up with her
PCP this week for a BP check.  She will need to continue her
aspirin and plavix indefinitely or until determined by her
cardiologist.  She will also need to restart her
anti-hypertensive medications as well.
.
# CAD: The patient is s/p stenting of proximal LAD with a 2.5 x
18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
 8mm Cypher to the OM1. A 3.5 x 18mm Cypher DES was also placed
to the mid RCA.  These were all done on prior admissions.  The
patient was chest pain free during this hospitalization, and she
will con't ASA, plavix, statin, and anti-hypertensives after
discharge.
.
# Hyperlipidemia: The patient will continue her outpatient
statin dose.
.
# H/o GIB: The patient's HCT remained stable during this
hospitalization.

Medications on Admission:
Aspirin 325mg daily in the am
Plavix 75mg daily in the am
Atenolol 25mg daily in the am
Triamterene/hctz 37.5/25mg daily in the am
Lipitor 80mg [**2-7**] tablet daily in the pm
Xalatan 0.005% 1 gtt OU qHS
Cosupt 1gtt OU [**Hospital1 **]


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).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day:
restart on [**2113-12-7**].
7. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1)
Tablet PO once a day: restart [**2113-12-7**].


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1110**] VNA

Discharge Diagnosis:
Primary Diagnosis: Right Carotid Angiography and Stent Placement
Secondary Diagnosis:
Coronary Artery Disease
Peripheral Arterial Disease
Hypertension
Hyperlipidemia


Discharge Condition:
stable


Discharge Instructions:
You were admitted for elective right carotid angiography and
intervention.  You had a stent placed in your right carotid
artery because of a blockage.  You tolerated the procedure well.
 You had a slightly low blood pressure that responsed well to IV
fluids.  You were discharged home without any complications.

Please hold your blood pressure medications and restart them on
[**2113-12-7**].  Please take all other medications as prescribed.
Please go to all appointments as scheduled.

If you develop any of the following concerning symptoms, please
call Dr [**First Name (STitle) **]: chest pain, shortness of breath, weakness or
numbness in the extremities, sudden loss of vision, difficulty
speaking, or headaches.

Followup Instructions:
Appointment made with your PCP [**Last Name (NamePattern4) **] [**2113-12-8**] at 12:15 PM

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2114-1-4**] 9:30
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2114-1-4**]
10:30
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2114-1-4**]
1:00
{'Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Peripheral vascular disease, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Percutaneous transluminal coronary angioplasty status,Personal history of other diseases of digestive system,Morbid obesity,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Macular degeneration (senile), unspecified,Old myocardial infarction,Examination of participant in clinical trial'}


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: elective right carotid angiography and possible stenting

PRESENT ILLNESS: 78 yo female with known coronary artery and peripheral [**First Name3 (LF) 1106**]
disease, status post AMI and LAD, LCX and left carotid
revascularizations in [**Month (only) 205**], now referred for right carotid
angiography and possible revascularization.
.
The patient states that she had been in her usual state of
health, and is now here for elective
angiography/revascularization. In [**8-12**], the patient had an
anterior STEMI and was taken to the cath lab at [**Hospital1 **], where
she was found to have an 80%
proximal LAD stenosis, an 80-90% LCX stenosis, an 80% RCA
stenosis and a 60-70% ramus stenosis. Given her 3 vessel
disease.
she was transferred to [**Hospital1 18**] for evaluation by CT surgery for
possible CABG A carotid ultrasound was done as part of her
evaluation and she was found to have 80-90% bilateral carotid
stenosis, making her a poor surgical candidate. She was also
found to have poor conduits due to prior vein stripping. She was

MEDICAL HISTORY: CARDIAC HISTORY:
Percutaneous coronary intervention, in anatomy as follows:
stenting of proximal LAD with a 2.5 x 18mm Cypher DES
3.0 x 18mm Cypher stent placed to the mid circumflex and a 2.5 x
 8mm Cypher to the OM1.
A 3.5 x 18mm Cypher DES was also placed to the mid RCA.
left internal carotid placement of a [**7-14**] x 30mm acculink stent.

MEDICATION ON ADMISSION: Aspirin 325mg daily in the am
Plavix 75mg daily in the am
Atenolol 25mg daily in the am
Triamterene/hctz 37.5/25mg daily in the am
Lipitor 80mg [**2-7**] tablet daily in the pm
Xalatan 0.005% 1 gtt OU qHS
Cosupt 1gtt OU [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 97.3, BP 102/39 , HR 58 , RR 20, O2 96% on RA
Gen: elderly obese female in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. right pupil 3 mm, left pupil 1
mm, non reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
Neck: Supple with JVP 6-8 cm
CV: RRR, normal S1, S2. No S4, no S3.
Chest:Resp were unlabored, no accessory muscle use. Clear
anteriorly. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND. No abdominial bruits.
Ext: 1+ BLE edema, chronic venous stasis changes. No femoral
bruits. right groin central line in place, no tenderness, no
hematoma, no thrill.
Pulses:
Right: Carotid 2+ without bruit; 1+ DP, 2+ PT
[**Name (NI) 2325**]: Carotid 2+ with bruit; 1+ DP, 2+ PT

FAMILY HISTORY: Her Father had a heart attack at age 64. There is no family
history of premature coronary artery disease or sudden death.

SOCIAL HISTORY: Married, lives at home with her husband. Retired. Daughter,
[**Name (NI) 1785**] is very involved in patient??????s care The patient does not
drink any alcohol. She denies history of drug use. She currently
does not smoke; but has a 40+ pack year history. Currently has
[**Location (un) 1110**] VNA 

### Response:
{'Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Peripheral vascular disease, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Percutaneous transluminal coronary angioplasty status,Personal history of other diseases of digestive system,Morbid obesity,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Macular degeneration (senile), unspecified,Old myocardial infarction,Examination of participant in clinical trial'}
