CHIEF COMPLAINT: Chest pain
.
HPI: Ms. [**Known lastname **] is a 64 yo female with history of an MI who
presented to an OSH on [**9-7**] with 9/10 burning chest pain and
right shoulder pain. Her EKG at the OSH showed bigeminy with a
rate of 158, STE in aVR & V1, STD in I, II, F, V3 - V6. Troponin
was elevated at 2.04. She was given SLNTG & morphine and was
started on a nitro gtt and her pain improved. She underwent
cardiac catheterization at [**Hospital3 **] which showed: RCA
chronically occluded, Cx with tight disease, + LAD disease. She
then went into atrial fibrillation (per outside report, no EKG
available) which is new for her and was treated with IV
Lopressor with successful conversion.
.
She was transferred to [**Hospital1 18**] for further evaluation for possible
CABG for her 3VD. Since her admission, pt continues to have
chest pain, similar to what she had at the OSH. She describes
the pain as a burning sensation with some radiation to her right
shoulder. Denies any associated SOB, PND, orthopnea, or
dizziness. Her cardiac enzymes remain elevated. She had an
episode of SVT on the floor with HR of 115. No new EKG changes
at the time. She had a carotid ultrasound which showed bilateral
stenosis, 60-69%.
.
She was transferred to the CCU for closer management. She is
currently asymptomatic.
.
Medications:
Heparin gtt
Nitro gtt
Lipitor 10mg PO daily
ASA 325mg PO daily
Metoprolol 50mg [**Hospital1 **]
Prednisolone eye gtt
Tobramycin eye gtt
Cyclopentolate eye gtt
.

PRESENT ILLNESS: 64 yo F presented to OSH with CP, +NSTEMI. Cath there showed
3VD, transferred to [**Hospital1 18**] for PCI v CABG.

MEDICAL HISTORY: Past Medical History:
1) CAD: MI [**2142**] - no intervention. S/p PCI in [**2147**], no
intervention at that time.
2) Retinal detachment s/p repair on [**9-4**].
3) s/p Tonsillectomy
4) s/p Cataract surgery
.

MEDICATION ON ADMISSION: asa

ALLERGIES: Nitrous Oxide

PHYSICAL EXAM: vitals T 98.7 BP 106/73 AR 54 RR 14
Gen: Pleasant female, NAD
HEENT: PERRLA, MMM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: CTAB, no crackles
Abdomen: soft, NT/ND, +BS, no organomegaly
Extremities: no edema, 2+ DP/PT pulses
.
Laboratory results: see below
.
EKG: Sinus bradycardia at 57. Small Q in II, III, F. J point ele
in V3 with no significant change compared with prior dated
[**2155-9-8**] earlier today. EKGs at OSH showed vent bigeminy.
.
Relevant Imaging:
.
1)Cardiac cath (OSH-[**9-8**]):100% RCA, 80 - 85% LCx, "Mod LAD", EF
55%. no formal report sent.
.
2)Carotid U/S ([**9-9**]):60-69% stenosis in the proximal internal
carotid arteries bilaterally.  This is a baseline examination at
the [**Hospital1 18**].
.
3)ECHO ([**9-9**]): 1. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. 2.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.  3. The mitral valve leaflets are mildly
thickened
.
A/P: Ms. [**Known lastname **] is a 64 yo female with history of MI, 3VD on
recent cardiac cath, bilateral carotid stenosis being
transferred to the CCU for closer management as well as
evaluation for CABG.
.
CARDIAC
1)3VD: Pt presented with chest pain at OSH and was found to have
significant 3VD on cardiac catheterization. She was transferred
to [**Hospital1 18**] for further evaluation and possible CABG. Pt being
followed by CT surgery.
- [**Hospital **] medical management w/statin, b-blocker, aspirin
- Hold Plavix and Integrillin given possible surgery and that
she unlikely does not have an unstable plaque, more likely
demand ischemia in the setting of tachycardia.
- ECHO, U/A, CXR, T+S as per CT surgery
- Continue nitro gtt and titrate down as necessary
- [**Hospital **] consult, as below; f/u reccs
- F/u CT surgery reccs
.
2)Rhythm: Pt in sinus rhythm on admission; she has episodes of
tachycardia (with multiple APCs)associated with ST changes (not
new), likely demand ischemia.
- Ct with Metoprolol 50 [**Hospital1 **], titrate up as necessary
.
2) LV Function: No history of CHF; appears to be normovolemic on
clinical exam.
- pre-op ECHO this afternoon
.
3)Bilateral carotid stenosis: Ultrasound from today shows 60-69%
carotid stenosis bilaterally. Currently asymptomatic.
- [**Hospital1 **] surgery consult regarding surgical intervention (CEA
vs. stent placement) and if this needs to be done prior to CABG.
.
4)Retinal detachment: s/p bubble procedure, pt being followed by
opthamology. Per opthamology, pt able to lye supine as well as
receive high doses of heparin. Per optho, pt able to lye supine
for surgery.
- Ct with outpatient regimen: Alphagan, Pred Forte, Tobramycin,
Cyclopent; the latter 2 can be stopped on [**9-11**].
- No nitrous oxide for anesthesia due to increased IOP.
- F/u opthamology reccs
.
5)FEN: Cardiac healthy diet, NPO after MN for likely CABG
tommorow, replete electrolytes as necessary.
.
6)Access: 1 PIV
.
7)Code: Full
.
8)Prophylaxis: Heparin IV for DVT prophylaxis, bowel regimen not
necessary at this time.
.
9)Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68948**], daughter: H [**Telephone/Fax (1) 68949**], C
[**Telephone/Fax (1) 68950**], W [**Telephone/Fax (1) 68951**].
.
10)Dispo: Pending possible CABG and clinical improvement
.

FAMILY HISTORY: Family History: There is a + family history of premature
coronary artery disease - dad had MI in 40's, mom had "heart
problems and [**Name (NI) 2320**]"

SOCIAL HISTORY: She works in the post office and does a lot of
heavy lifting. Significant tobacco use - at least a pack a day
for 44 years. Occasional alcohol abuse.
.
Physical Exam:
vitals T 98.7 BP 106/73 AR 54 RR 14
Gen: Pleasant female, NAD
HEENT: PERRLA, MMM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: CTAB, no crackles
Abdomen: soft, NT/ND, +BS, no organomegaly
Extremities: no edema, 2+ DP/PT pulses
.
Laboratory results: see below
.
EKG: Sinus bradycardia at 57. Small Q in II, III, F. J point ele
in V3 with no significant change compared with prior dated
[**2155-9-8**] earlier today. EKGs at OSH showed vent bigeminy.
.
Relevant Imaging:
.
1)Cardiac cath (OSH-[**9-8**]):100% RCA, 80 - 85% LCx, "Mod LAD", EF
55%. no formal report sent.
.
2)Carotid U/S ([**9-9**]):60-69% stenosis in the proximal internal
carotid arteries bilaterally.  This is a baseline examination at
the [**Hospital1 18**].
.
3)ECHO ([**9-9**]): 1. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. 2.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.  3. The mitral valve leaflets are mildly
thickened
.
A/P: Ms. [**Known lastname **] is a 64 yo female with history of MI, 3VD on
recent cardiac cath, bilateral carotid stenosis being
transferred to the CCU for closer management as well as
evaluation for CABG.
.
CARDIAC
1)3VD: Pt presented with chest pain at OSH and was found to have
significant 3VD on cardiac catheterization. She was transferred
to [**Hospital1 18**] for further evaluation and possible CABG. Pt being
followed by CT surgery.
- [**Hospital **] medical management w/statin, b-blocker, aspirin
- Hold Plavix and Integrillin given possible surgery and that
she unlikely does not have an unstable plaque, more likely
demand ischemia in the setting of tachycardia.
- ECHO, U/A, CXR, T+S as per CT surgery
- Continue nitro gtt and titrate down as necessary
- [**Hospital **] consult, as below; f/u reccs
- F/u CT surgery reccs
.
2)Rhythm: Pt in sinus rhythm on admission; she has episodes of
tachycardia (with multiple APCs)associated with ST changes (not
new), likely demand ischemia.
- Ct with Metoprolol 50 [**Hospital1 **], titrate up as necessary
.
2) LV Function: No history of CHF; appears to be normovolemic on
clinical exam.
- pre-op ECHO this afternoon
.
3)Bilateral carotid stenosis: Ultrasound from today shows 60-69%
carotid stenosis bilaterally. Currently asymptomatic.
- [**Hospital1 **] surgery consult regarding surgical intervention (CEA
vs. stent placement) and if this needs to be done prior to CABG.
.
4)Retinal detachment: s/p bubble procedure, pt being followed by
opthamology. Per opthamology, pt able to lye supine as well as
receive high doses of heparin. Per optho, pt able to lye supine
for surgery.
- Ct with outpatient regimen: Alphagan, Pred Forte, Tobramycin,
Cyclopent; the latter 2 can be stopped on [**9-11**].
- No nitrous oxide for anesthesia due to increased IOP.
- F/u opthamology reccs
.
5)FEN: Cardiac healthy diet, NPO after MN for likely CABG
tommorow, replete electrolytes as necessary.
.
6)Access: 1 PIV
.
7)Code: Full
.
8)Prophylaxis: Heparin IV for DVT prophylaxis, bowel regimen not
necessary at this time.
.
9)Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68948**], daughter: H [**Telephone/Fax (1) 68949**], C
[**Telephone/Fax (1) 68950**], W [**Telephone/Fax (1) 68951**].
.
10)Dispo: Pending possible CABG and clinical improvement
.
Subendocardial infarction, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Family history of ischemic heart disease,Other noninfectious disorders of lymphatic channels,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Anemia, unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other forms of retinal detachment
Subendo infarct, initial,Accidental op laceration,Parox ventric tachycard,Crnry athrscl natve vssl,Fam hx-ischem heart dis,Noninfect lymph dis NEC,Acc cut/hem in surgery,Anemia NOS,Ocl crtd art wo infrct,Retinal detachment NEC
Admission Date:  [**2155-9-8**]              Discharge Date:   [**2155-10-6**]

Date of Birth:  [**2091-3-26**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Nitrous Oxide

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
.
HPI: Ms. [**Known lastname **] is a 64 yo female with history of an MI who
presented to an OSH on [**9-7**] with 9/10 burning chest pain and
right shoulder pain. Her EKG at the OSH showed bigeminy with a
rate of 158, STE in aVR & V1, STD in I, II, F, V3 - V6. Troponin
was elevated at 2.04. She was given SLNTG & morphine and was
started on a nitro gtt and her pain improved. She underwent
cardiac catheterization at [**Hospital3 **] which showed: RCA
chronically occluded, Cx with tight disease, + LAD disease. She
then went into atrial fibrillation (per outside report, no EKG
available) which is new for her and was treated with IV
Lopressor with successful conversion.
.
She was transferred to [**Hospital1 18**] for further evaluation for possible
CABG for her 3VD. Since her admission, pt continues to have
chest pain, similar to what she had at the OSH. She describes
the pain as a burning sensation with some radiation to her right
shoulder. Denies any associated SOB, PND, orthopnea, or
dizziness. Her cardiac enzymes remain elevated. She had an
episode of SVT on the floor with HR of 115. No new EKG changes
at the time. She had a carotid ultrasound which showed bilateral
stenosis, 60-69%.
.
She was transferred to the CCU for closer management. She is
currently asymptomatic.
.
Medications:
Heparin gtt
Nitro gtt
Lipitor 10mg PO daily
ASA 325mg PO daily
Metoprolol 50mg [**Hospital1 **]
Prednisolone eye gtt
Tobramycin eye gtt
Cyclopentolate eye gtt
.

.
Social History: She works in the post office and does a lot of
heavy lifting. Significant tobacco use - at least a pack a day
for 44 years. Occasional alcohol abuse.
.
Physical Exam:
vitals T 98.7 BP 106/73 AR 54 RR 14
Gen: Pleasant female, NAD
HEENT: PERRLA, MMM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: CTAB, no crackles
Abdomen: soft, NT/ND, +BS, no organomegaly
Extremities: no edema, 2+ DP/PT pulses
.
Laboratory results: see below
.
EKG: Sinus bradycardia at 57. Small Q in II, III, F. J point ele
in V3 with no significant change compared with prior dated
[**2155-9-8**] earlier today. EKGs at OSH showed vent bigeminy.
.
Relevant Imaging:
.
1)Cardiac cath (OSH-[**9-8**]):100% RCA, 80 - 85% LCx, "Mod LAD", EF
55%. no formal report sent.
.
2)Carotid U/S ([**9-9**]):60-69% stenosis in the proximal internal
carotid arteries bilaterally.  This is a baseline examination at
the [**Hospital1 18**].
.
3)ECHO ([**9-9**]): 1. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. 2.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.  3. The mitral valve leaflets are mildly
thickened
.
A/P: Ms. [**Known lastname **] is a 64 yo female with history of MI, 3VD on
recent cardiac cath, bilateral carotid stenosis being
transferred to the CCU for closer management as well as
evaluation for CABG.
.
CARDIAC
1)3VD: Pt presented with chest pain at OSH and was found to have
significant 3VD on cardiac catheterization. She was transferred
to [**Hospital1 18**] for further evaluation and possible CABG. Pt being
followed by CT surgery.
- [**Hospital **] medical management w/statin, b-blocker, aspirin
- Hold Plavix and Integrillin given possible surgery and that
she unlikely does not have an unstable plaque, more likely
demand ischemia in the setting of tachycardia.
- ECHO, U/A, CXR, T+S as per CT surgery
- Continue nitro gtt and titrate down as necessary
- [**Hospital **] consult, as below; f/u reccs
- F/u CT surgery reccs
.
2)Rhythm: Pt in sinus rhythm on admission; she has episodes of
tachycardia (with multiple APCs)associated with ST changes (not
new), likely demand ischemia.
- Ct with Metoprolol 50 [**Hospital1 **], titrate up as necessary
.
2) LV Function: No history of CHF; appears to be normovolemic on
clinical exam.
- pre-op ECHO this afternoon
.
3)Bilateral carotid stenosis: Ultrasound from today shows 60-69%
carotid stenosis bilaterally. Currently asymptomatic.
- [**Hospital1 **] surgery consult regarding surgical intervention (CEA
vs. stent placement) and if this needs to be done prior to CABG.
.
4)Retinal detachment: s/p bubble procedure, pt being followed by
opthamology. Per opthamology, pt able to lye supine as well as
receive high doses of heparin. Per optho, pt able to lye supine
for surgery.
- Ct with outpatient regimen: Alphagan, Pred Forte, Tobramycin,
Cyclopent; the latter 2 can be stopped on [**9-11**].
- No nitrous oxide for anesthesia due to increased IOP.
- F/u opthamology reccs
.
5)FEN: Cardiac healthy diet, NPO after MN for likely CABG
tommorow, replete electrolytes as necessary.
.
6)Access: 1 PIV
.
7)Code: Full
.
8)Prophylaxis: Heparin IV for DVT prophylaxis, bowel regimen not
necessary at this time.
.
9)Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68948**], daughter: H [**Telephone/Fax (1) 68949**], C
[**Telephone/Fax (1) 68950**], W [**Telephone/Fax (1) 68951**].
.
10)Dispo: Pending possible CABG and clinical improvement
.

Major Surgical or Invasive Procedure:
[**9-11**] CABG x 4
[**9-25**] R VATS/Thoracic duct clipping


History of Present Illness:
64 yo F presented to OSH with CP, +NSTEMI. Cath there showed
3VD, transferred to [**Hospital1 18**] for PCI v CABG.

Past Medical History:
Past Medical History:
1) CAD: MI [**2142**] - no intervention. S/p PCI in [**2147**], no
intervention at that time.
2) Retinal detachment s/p repair on [**9-4**].
3) s/p Tonsillectomy
4) s/p Cataract surgery
.


Social History:
lives with daughters
works at post office
1 ppd x 44 years
social etoh

Family History:
Family History: There is a + family history of premature
coronary artery disease - dad had MI in 40's, mom had "heart
problems and [**Name (NI) 2320**]"

Physical Exam:
70 20 108/50
NAD
HEENT r eye bloodshot, pupil nonreactive, L pupil reactive
No lympadenopathy
Lungs CTAB ant/post
Heart RRR, no M/R/G
Abd benign
Extrem warm, no edema
1+ DP/PT/femoral pulses, 2+ radial pulses


Pertinent Results:
[**2155-10-6**] 06:50AM BLOOD WBC-4.2 RBC-3.56* Hgb-10.0* Hct-28.8*
MCV-81* MCH-28.0 MCHC-34.6 RDW-16.5* Plt Ct-213
[**2155-10-6**] 06:50AM BLOOD Plt Ct-213
[**2155-9-29**] 03:09AM BLOOD PT-13.2* PTT-26.7 INR(PT)-1.2*
[**2155-10-6**] 06:50AM BLOOD Glucose-106* UreaN-28* Creat-0.9 Na-140
K-4.1 Cl-104 HCO3-30 AnGap-10

Brief Hospital Course:
Ms. [**Known lastname **] was seen by opthomology for her recent retinal
detachment and gas bubble placement. She was ok'd for
anticoagulation with heparin. She was seen in consultation by
[**Known lastname 1106**] surgery for her bilateral carotid stenosis of 60-69,
she will have a repeat carotid u/s in 6 months, and see Dr.
[**Last Name (STitle) **] as an outpatient. Ms. [**Known lastname **] was taken to the operating
room on [**2155-9-10**] where she underwent a CABG x 4. She was
transferred to the SICU in critical but stable condition. She
was extubated later that same day. The following day she was
reintubated for low CO and possible ischemia. She was started on
milrinone, and remained on amiodarone (for some VT postop) and
neo. TEE showed no areas of potential ischemia. She was again
extubated on POD #2. She was again reintubated late on POD #3
for hypoxia. Bronchoscopy showed minimal amounts of clear
secretions. She was ready for extubated on POD #5. ON [**9-18**], she
underwent a thoracentesis for ~2L cloudy fluid. The fluid was
positive for triglycerides. She was transferred to the floor. A
repeat CXR showed almost complete reaccumulation of the
chylothorax and a chest tube was placed. She was started on TPN
and made NPO. She was seen in constulation by thoracic surgery,
and on [**2155-9-25**] she underwent a right VATS and thoracic duct
ligation. She was given clear liquids and reminade on TPN. She
was transferred back to the floor 11.13. She was started on a
regular diet which she tolerated. Her chest tubes were
discontinued with small stable bilated pneumothoraces. She was
placd on keflex for some continued mild erythema of her sternal
incision. She was ready for discharge home on POD #25/11.

Medications on Admission:
asa


Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
6. 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:*0*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 5
days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
10. Cyclopentolate 1 % Drops Sig: One (1) Drop Ophthalmic  [**Hospital1 **]
(2 times a day): right eye.
Disp:*QS  1 month* Refills:*0*
11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic  QID (4 times a day): right eye only.
Disp:*QS 1 month* Refills:*0*
12. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic  [**Hospital1 **]
(2 times a day): right eye only.
Disp:*QS 1 month* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every
2 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
CAD
Chylothorax
MI ([**2142**])
PCI [**2147**]
retinal detachment
teonsils
cataract surgery


Discharge Condition:
Good.


Discharge Instructions:
Call with fever, redness or draiange from incision or weight
gain more than 2 pounds in one day or five in one week.
No heavy lifting or driving until follow up with surgeon or
while taking narcotic pain medicine.
Shower, no baths, no lotions, creams or powders to incisions.
Bandaid to chest tube sites.


Followup Instructions:
Dr. [**Last Name (STitle) 5017**] 2 weeks
Dr. [**Last Name (STitle) 33575**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) **] [**Name (STitle) **] office to make follow up and appointment
and appointment for CXR
[**Doctor First Name 6811**] STONE, RVT Date/Time:[**2156-2-18**] 10:00
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2156-2-18**]
11:00

Dr. [**Last Name (STitle) 68952**] (Opthamology) after discharge



Completed by:[**2155-10-8**]
{'Subendocardial infarction, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Family history of ischemic heart disease,Other noninfectious disorders of lymphatic channels,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Anemia, unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other forms of retinal detachment'}


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
.
HPI: Ms. [**Known lastname **] is a 64 yo female with history of an MI who
presented to an OSH on [**9-7**] with 9/10 burning chest pain and
right shoulder pain. Her EKG at the OSH showed bigeminy with a
rate of 158, STE in aVR & V1, STD in I, II, F, V3 - V6. Troponin
was elevated at 2.04. She was given SLNTG & morphine and was
started on a nitro gtt and her pain improved. She underwent
cardiac catheterization at [**Hospital3 **] which showed: RCA
chronically occluded, Cx with tight disease, + LAD disease. She
then went into atrial fibrillation (per outside report, no EKG
available) which is new for her and was treated with IV
Lopressor with successful conversion.
.
She was transferred to [**Hospital1 18**] for further evaluation for possible
CABG for her 3VD. Since her admission, pt continues to have
chest pain, similar to what she had at the OSH. She describes
the pain as a burning sensation with some radiation to her right
shoulder. Denies any associated SOB, PND, orthopnea, or
dizziness. Her cardiac enzymes remain elevated. She had an
episode of SVT on the floor with HR of 115. No new EKG changes
at the time. She had a carotid ultrasound which showed bilateral
stenosis, 60-69%.
.
She was transferred to the CCU for closer management. She is
currently asymptomatic.
.
Medications:
Heparin gtt
Nitro gtt
Lipitor 10mg PO daily
ASA 325mg PO daily
Metoprolol 50mg [**Hospital1 **]
Prednisolone eye gtt
Tobramycin eye gtt
Cyclopentolate eye gtt
.

PRESENT ILLNESS: 64 yo F presented to OSH with CP, +NSTEMI. Cath there showed
3VD, transferred to [**Hospital1 18**] for PCI v CABG.

MEDICAL HISTORY: Past Medical History:
1) CAD: MI [**2142**] - no intervention. S/p PCI in [**2147**], no
intervention at that time.
2) Retinal detachment s/p repair on [**9-4**].
3) s/p Tonsillectomy
4) s/p Cataract surgery
.

MEDICATION ON ADMISSION: asa

ALLERGIES: Nitrous Oxide

PHYSICAL EXAM: vitals T 98.7 BP 106/73 AR 54 RR 14
Gen: Pleasant female, NAD
HEENT: PERRLA, MMM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: CTAB, no crackles
Abdomen: soft, NT/ND, +BS, no organomegaly
Extremities: no edema, 2+ DP/PT pulses
.
Laboratory results: see below
.
EKG: Sinus bradycardia at 57. Small Q in II, III, F. J point ele
in V3 with no significant change compared with prior dated
[**2155-9-8**] earlier today. EKGs at OSH showed vent bigeminy.
.
Relevant Imaging:
.
1)Cardiac cath (OSH-[**9-8**]):100% RCA, 80 - 85% LCx, "Mod LAD", EF
55%. no formal report sent.
.
2)Carotid U/S ([**9-9**]):60-69% stenosis in the proximal internal
carotid arteries bilaterally.  This is a baseline examination at
the [**Hospital1 18**].
.
3)ECHO ([**9-9**]): 1. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. 2.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.  3. The mitral valve leaflets are mildly
thickened
.
A/P: Ms. [**Known lastname **] is a 64 yo female with history of MI, 3VD on
recent cardiac cath, bilateral carotid stenosis being
transferred to the CCU for closer management as well as
evaluation for CABG.
.
CARDIAC
1)3VD: Pt presented with chest pain at OSH and was found to have
significant 3VD on cardiac catheterization. She was transferred
to [**Hospital1 18**] for further evaluation and possible CABG. Pt being
followed by CT surgery.
- [**Hospital **] medical management w/statin, b-blocker, aspirin
- Hold Plavix and Integrillin given possible surgery and that
she unlikely does not have an unstable plaque, more likely
demand ischemia in the setting of tachycardia.
- ECHO, U/A, CXR, T+S as per CT surgery
- Continue nitro gtt and titrate down as necessary
- [**Hospital **] consult, as below; f/u reccs
- F/u CT surgery reccs
.
2)Rhythm: Pt in sinus rhythm on admission; she has episodes of
tachycardia (with multiple APCs)associated with ST changes (not
new), likely demand ischemia.
- Ct with Metoprolol 50 [**Hospital1 **], titrate up as necessary
.
2) LV Function: No history of CHF; appears to be normovolemic on
clinical exam.
- pre-op ECHO this afternoon
.
3)Bilateral carotid stenosis: Ultrasound from today shows 60-69%
carotid stenosis bilaterally. Currently asymptomatic.
- [**Hospital1 **] surgery consult regarding surgical intervention (CEA
vs. stent placement) and if this needs to be done prior to CABG.
.
4)Retinal detachment: s/p bubble procedure, pt being followed by
opthamology. Per opthamology, pt able to lye supine as well as
receive high doses of heparin. Per optho, pt able to lye supine
for surgery.
- Ct with outpatient regimen: Alphagan, Pred Forte, Tobramycin,
Cyclopent; the latter 2 can be stopped on [**9-11**].
- No nitrous oxide for anesthesia due to increased IOP.
- F/u opthamology reccs
.
5)FEN: Cardiac healthy diet, NPO after MN for likely CABG
tommorow, replete electrolytes as necessary.
.
6)Access: 1 PIV
.
7)Code: Full
.
8)Prophylaxis: Heparin IV for DVT prophylaxis, bowel regimen not
necessary at this time.
.
9)Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68948**], daughter: H [**Telephone/Fax (1) 68949**], C
[**Telephone/Fax (1) 68950**], W [**Telephone/Fax (1) 68951**].
.
10)Dispo: Pending possible CABG and clinical improvement
.

FAMILY HISTORY: Family History: There is a + family history of premature
coronary artery disease - dad had MI in 40's, mom had "heart
problems and [**Name (NI) 2320**]"

SOCIAL HISTORY: She works in the post office and does a lot of
heavy lifting. Significant tobacco use - at least a pack a day
for 44 years. Occasional alcohol abuse.
.
Physical Exam:
vitals T 98.7 BP 106/73 AR 54 RR 14
Gen: Pleasant female, NAD
HEENT: PERRLA, MMM
Heart: nl s1/s2, no s3/s4, no m,r,g
Lungs: CTAB, no crackles
Abdomen: soft, NT/ND, +BS, no organomegaly
Extremities: no edema, 2+ DP/PT pulses
.
Laboratory results: see below
.
EKG: Sinus bradycardia at 57. Small Q in II, III, F. J point ele
in V3 with no significant change compared with prior dated
[**2155-9-8**] earlier today. EKGs at OSH showed vent bigeminy.
.
Relevant Imaging:
.
1)Cardiac cath (OSH-[**9-8**]):100% RCA, 80 - 85% LCx, "Mod LAD", EF
55%. no formal report sent.
.
2)Carotid U/S ([**9-9**]):60-69% stenosis in the proximal internal
carotid arteries bilaterally.  This is a baseline examination at
the [**Hospital1 18**].
.
3)ECHO ([**9-9**]): 1. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal. 2.
The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.  3. The mitral valve leaflets are mildly
thickened
.
A/P: Ms. [**Known lastname **] is a 64 yo female with history of MI, 3VD on
recent cardiac cath, bilateral carotid stenosis being
transferred to the CCU for closer management as well as
evaluation for CABG.
.
CARDIAC
1)3VD: Pt presented with chest pain at OSH and was found to have
significant 3VD on cardiac catheterization. She was transferred
to [**Hospital1 18**] for further evaluation and possible CABG. Pt being
followed by CT surgery.
- [**Hospital **] medical management w/statin, b-blocker, aspirin
- Hold Plavix and Integrillin given possible surgery and that
she unlikely does not have an unstable plaque, more likely
demand ischemia in the setting of tachycardia.
- ECHO, U/A, CXR, T+S as per CT surgery
- Continue nitro gtt and titrate down as necessary
- [**Hospital **] consult, as below; f/u reccs
- F/u CT surgery reccs
.
2)Rhythm: Pt in sinus rhythm on admission; she has episodes of
tachycardia (with multiple APCs)associated with ST changes (not
new), likely demand ischemia.
- Ct with Metoprolol 50 [**Hospital1 **], titrate up as necessary
.
2) LV Function: No history of CHF; appears to be normovolemic on
clinical exam.
- pre-op ECHO this afternoon
.
3)Bilateral carotid stenosis: Ultrasound from today shows 60-69%
carotid stenosis bilaterally. Currently asymptomatic.
- [**Hospital1 **] surgery consult regarding surgical intervention (CEA
vs. stent placement) and if this needs to be done prior to CABG.
.
4)Retinal detachment: s/p bubble procedure, pt being followed by
opthamology. Per opthamology, pt able to lye supine as well as
receive high doses of heparin. Per optho, pt able to lye supine
for surgery.
- Ct with outpatient regimen: Alphagan, Pred Forte, Tobramycin,
Cyclopent; the latter 2 can be stopped on [**9-11**].
- No nitrous oxide for anesthesia due to increased IOP.
- F/u opthamology reccs
.
5)FEN: Cardiac healthy diet, NPO after MN for likely CABG
tommorow, replete electrolytes as necessary.
.
6)Access: 1 PIV
.
7)Code: Full
.
8)Prophylaxis: Heparin IV for DVT prophylaxis, bowel regimen not
necessary at this time.
.
9)Communication: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 68948**], daughter: H [**Telephone/Fax (1) 68949**], C
[**Telephone/Fax (1) 68950**], W [**Telephone/Fax (1) 68951**].
.
10)Dispo: Pending possible CABG and clinical improvement
. 

### Response:
{'Subendocardial infarction, initial episode of care,Accidental puncture or laceration during a procedure, not elsewhere classified,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Family history of ischemic heart disease,Other noninfectious disorders of lymphatic channels,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Anemia, unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other forms of retinal detachment'}
