CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain.
Patient recently came back from a trip to [**Male First Name (un) 1056**] with his
wife, had an episode of diffuse chest pressure with radiation
and numbness to left arm which resolved without any intervention
about 2 weeks ago while on vacation.  The chest pressure and
pain returned two days ago, initially with diffuse chest pain
[**9-27**] radiating to neck, arms, back, and LLQ of abdomen, but
this morning the pain was more localized to the left sided of
his chest and LLQ of abdomen with radiation to the back. He has
been taking Motrin 600mg PO q6h prn for his pain, which didn't
help.  The pain was associated with nausea and vomiting,
diarrhea, and occasional chills, no fever or diaphoresis.  Per
daughter and wife, he also had recent sick contact: his
granddaughter was having flu-like symptoms with fever, headache,
N/V/D.  Because of his unresolving chest pain, he came the [**Hospital1 18**]
ED where ECG was obtained which showed 1-2mm ST elevation in the
inferior leads.  Decision was made to take him to the cath lab
directly without his lab results.
.
In the Cath Lab: he was found to have normal LMCA, multiple
serial 70% stenosis in the LAD, Lcx diffuse disease: 90% OM1
stented, 70% OM2; 90% Mid RCA stented, 60% distal RCA
unintervened.  He was brought to [**Hospital1 1516**] service initially and
found to have a Cr of 6.1 (baseline 2.4), and K of 6.4, he was
transferred the CCU service for further management of his
cardiac and renal issues.  On presentation to CCU, he is
hemodynamically stable, he felt like he needs to urinate, but
really can't when he tries, and he has been have these symptoms
for more than half a year.  Foley cath was placed, and he was
started on dialysis.

MEDICAL HISTORY: 1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. hypercholesterolemia
4. schizophrenia diagnosed many years ago per family, but never
took any meds.
5. Carpal tunnel syndrome.
6. Depression (not on meds)
.

MEDICATION ON ADMISSION: Lescol XL 80mg PO qday (not very compliant due to GI upset)
lofibra 200mg PO qday (not very compliant due to GI upset)
Glipizide 10mg PO qday
Avandia 8mg PO qday
Nephrocaps 1 cap PO qday (hasn't been taken them for three
months)
Uni-daily (multivit)1 tab PO qday
Lasix 20mg PO qday
Atenolol 50mg PO qday
Ativan 2mg PO bid
Neurontin 400mg PO qday
Ducolax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE:
VS: T 95.1, BP 132/77 (equal on both sides), BP 79, RR 25, 97%
on 2L NS
GEN: lying flat, speaks no English, NAD
HEENT: PERRL. MMM. OP clear. no JVD and no bruits
HEART: RRR no m/r/g. distant heart sounds, no m/r/g appreciated.

FAMILY HISTORY: Significant for myocardial infarction in his father at the age
of 49.

SOCIAL HISTORY: The patient does not smoke and he does not drink alcohol. He
lives with his wife.
Acute myocardial infarction of other inferior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute pericarditis in diseases classified elsewhere,Acute respiratory failure,Urinary tract infection, site not specified,Unspecified pleural effusion,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Background diabetic retinopathy,Other and unspecified complications of medical care, not elsewhere classified,Anemia in chronic kidney disease,Diarrhea
AMI inferior wall, init,Crnry athrscl natve vssl,Acute kidney failure NOS,DMII renl nt st uncntrld,Hyp kid NOS w cr kid V,Ac pericardit in oth dis,Acute respiratry failure,Urin tract infection NOS,Pleural effusion NOS,Schizophrenia NOS-unspec,Hyperlipidemia NEC/NOS,Neuropathy in diabetes,Elev transaminase/ldh,Diabetic retinopathy NOS,Complic med care NEC/NOS,Anemia in chr kidney dis,Diarrhea
Admission Date:  [**2163-7-29**]              Discharge Date:   [**2163-8-13**]

Date of Birth:  [**2117-4-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
cardiac cath s/p two stents placement (one in OM1 and one in mid
RCA)
ETT placement
NG tube placement
temporary dialysis catheter placement
Cardiac catheterization
Pericardiocentesis
Endotracheal intubation
Temporary and permanent HD catheter placement
Initiation of Hemodialysis


History of Present Illness:
The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain.
Patient recently came back from a trip to [**Male First Name (un) 1056**] with his
wife, had an episode of diffuse chest pressure with radiation
and numbness to left arm which resolved without any intervention
about 2 weeks ago while on vacation.  The chest pressure and
pain returned two days ago, initially with diffuse chest pain
[**9-27**] radiating to neck, arms, back, and LLQ of abdomen, but
this morning the pain was more localized to the left sided of
his chest and LLQ of abdomen with radiation to the back. He has
been taking Motrin 600mg PO q6h prn for his pain, which didn't
help.  The pain was associated with nausea and vomiting,
diarrhea, and occasional chills, no fever or diaphoresis.  Per
daughter and wife, he also had recent sick contact: his
granddaughter was having flu-like symptoms with fever, headache,
N/V/D.  Because of his unresolving chest pain, he came the [**Hospital1 18**]
ED where ECG was obtained which showed 1-2mm ST elevation in the
inferior leads.  Decision was made to take him to the cath lab
directly without his lab results.
.
In the Cath Lab: he was found to have normal LMCA, multiple
serial 70% stenosis in the LAD, Lcx diffuse disease: 90% OM1
stented, 70% OM2; 90% Mid RCA stented, 60% distal RCA
unintervened.  He was brought to [**Hospital1 1516**] service initially and
found to have a Cr of 6.1 (baseline 2.4), and K of 6.4, he was
transferred the CCU service for further management of his
cardiac and renal issues.  On presentation to CCU, he is
hemodynamically stable, he felt like he needs to urinate, but
really can't when he tries, and he has been have these symptoms
for more than half a year.  Foley cath was placed, and he was
started on dialysis.


Past Medical History:
1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. hypercholesterolemia
4. schizophrenia diagnosed many years ago per family, but never
took any meds.
5. Carpal tunnel syndrome.
6. Depression (not on meds)
.


Social History:
The patient does not smoke and he does not drink alcohol. He
lives with his wife.

Family History:
Significant for myocardial infarction in his father at the age
of 49.


Physical Exam:
Admission PE:
VS: T 95.1, BP 132/77 (equal on both sides), BP 79, RR 25, 97%
on 2L NS
GEN: lying flat, speaks no English, NAD
HEENT: PERRL. MMM. OP clear. no JVD and no bruits
HEART: RRR no m/r/g. distant heart sounds, no m/r/g appreciated.

LUNGS: CTA anteriorly, no wheezing/rales/rhonchi
ABD: soft, slightly distented, NT, +BS,
Ext: 1+ DP pulses Left side, non-palpable, but dopplerable DP on
the right, no C/C/E
NEURO: A&O x 3. No focal deficits, no sensation to touch in
lower extremity bilaterally in stocking glove distribution


Pertinent Results:
Admission Labs:
[**2163-7-29**]  WBC-22.8  Hgb-10.1 Hct-29.7 MCV-89 Plt Ct-281
[**2163-7-29**]  Neuts-89.5 Bands-0 Lymphs-6.1 Monos-4.1 Eos-0.2
Baso-0.1
[**2163-7-29**]  PT-13.3 PTT-23.8 INR(PT)-1.2
[**2163-7-29**]  UreaN-77 Creat-6.1 Na-127 K-6.4 Cl-93 HCO3-16 Gap-24
[**2163-7-29**]  Glucose-348 UreaN-78 Creat-6.0 Na-127 K-6.6 Cl-95
HCO3-16
          AnGap-23
[**2163-7-29**] 04:34PM   CALCIUM-8.2* PHOSPHATE-6.0* MAGNESIUM-2.3
[**2163-7-29**]  CK(CPK)-171 CK-MB-15
[**2163-7-29**] 02:25PM   cTropnT-0.28*
[**2163-7-29**]  Type-ART O2 Flow-2 pO2-71* pCO2-32* pH-7.32*
calTCO2-17 Base XS-
          -8
[**2163-7-29**]  WBC-21.4 Hgb-8.8  Hct-25.0 MCV-87 Plt Ct-277
.
Other labs:
[**2163-7-29**]  CK 171 ->134->124-> 113 ([**2163-7-30**])
[**2163-7-29**]  CKMB 15->13->12->8 ([**2163-7-30**])
[**2163-7-31**]  TSH-6.5* Free T4-1.3
[**2163-7-30**]  PTH-146
[**2163-7-31**]  HBsAb-POSITIVE HBcAb-NEGATIVE [**Doctor First Name **]-NEGATIVE HCV
Ab-NEGATIVE
[**2163-7-31**]  pericardial fluid, TotProt- 4.5 Glucose- 51
LD(LDH)-3636
          Amylase-35 Albumin- 2.5
          WBC-[**Numeric Identifier 28577**] RBC-2556 Polys-90 Lymphs-0 Monos-6 Macro-4
[**2163-8-2**]  calTIBC 187*  Ferritn 1031* TRF 144* Iron 16*
[**2163-7-30**]  HbA1C 7.2
[**2163-7-30**]  Cholest  201* Triglyc 191* HDL 43 LDLcalc 120
[**2163-8-11**]  HBsAg negative; HBsAb negative; HBcAb negative; HCV ab
negative
[**2163-7-31**]  [**Doctor First Name **] negative
.
Micro:
PERICARDIAL FLUID ([**2163-7-31**]):
GRAM STAIN (Final [**2163-7-31**])
2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):    NO GROWTH.
ANAEROBIC CULTURE (Preliminary):    NO GROWTH.
ACID FAST SMEAR (Final [**2163-8-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
Sputum ([**2163-7-31**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE.HEAVY GROWTH.BEING ISOLATED FOR
SENSITIVITIES.
RESPIRATORY CULTURE (Preliminary):
STREPTOCOCCUS PNEUMONIAE.HEAVY GROWTH.
Possible penicillin resistance by oxacillin screen.
Resistance to be confirmed by MIC testing.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
.
SENSITIVITIES ([**2163-8-4**]): MIC expressed in MCG/ML
               STREPTOCOCCUS PNEUMONIAE
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------                2 S
CEFTAZIDIME-----------                4 S
CEFTRIAXONE-----------  0.12 S
CIPROFLOXACIN---------           <=0.25 S
ERYTHROMYCIN----------   =>1 R
GENTAMICIN------------                4 S
IMIPENEM--------------              <=1 S
LEVOFLOXACIN----------     1 S
MEROPENEM-------------           <=0.25 S
PENICILLIN------------  0.25 I
PIPERACILLIN----------                8 S
PIPERACILLIN/TAZO-----                8 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

.
ENTEROCOCCUS SP.
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------       S
.
[**2163-8-7**]  STOOL FINAL REPORT [**2163-8-8**]
   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-8**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.
[**2163-8-8**]  CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-8**]):
          FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
          Reference Range:  Negative.
[**2163-8-10**]:  CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2163-8-11**]):
          FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
          Reference Range:  Negative.
.
Imaging:
ECG ([**2163-7-29**]): SR at 75, normal interval, nomral axis, 1-2mm ST
elevation on lead II, II, AvF (inferor leads)
.
Cath Report ([**2163-7-29**]):
co-dominant
LMCA: normal
LAD: multiple serial 70% stenosis with intervening normal
segements (seen in all three arteries)
LCX: diffuse disease, 90% OM1 (lower pole)-> stented -> 0%
residual, 70% OM2
RCA: 90% mid (hazy) with 60% distal diffuse disease-> spot
stented the mid RCA ->0% residual.  Left distal diffuse disease
untreated.
.
Radiology:
CXR ([**2163-7-29**]):
1. Enlarged cardiac contour consistent with cardiomegaly and/or
pericardiac effusion.
2. Widened mediastinum of unknown etiology warrants further
evaluation with CT
3. Left lower lobe retrocardiac consolidation/atelectasis.
.
Echo ([**2163-7-30**]):
Conclusions:
1. The left ventricular cavity size is normal. There is mild
global left
ventricular hypokinesis with inferior akinesis. Overall left
ventricular
systolic function is mildly depressed.
2. The aortic valve leaflets (3) are mildly thickened. No aortic
regurgitation is seen.
3. There is a large, circumferential, pericardial effusion.
There are no
echocardiographic signs of tamponade.
4. There is a large pleural effusion.
.
CT chest ([**2163-7-30**]):
IMPRESSION:
1.  No evidence of pulmonary embolism or aortic dissection.
2.  Large pericardial effusion.
3.  Bilateral pleural effusions, moderate on the right and small
on the left,with corresponding bilateral lower lobe atelectasis.

.
Pericardiocentesis ([**2163-7-31**]):
COMMENTS:
1. Pericardiocentesis was successfully performed, yielding 465cc
of
cloudy yellow fluid without resistance or complication.  No
additional
catheters were placed as a pulmonary artery line and radial
arterial
line were already in place.
2. Hemodynamic studies were notable for near equalization of
right
atrial and pericardial pressures with mean 25 and 24mmHg,
respectively.
Post-procedural pericardial pressures were 8 mmHg with mean
right atrial
pressures of 19mmHg.
3. Postprocedural echo was immediately performed and showed
small
residual pericardial effusion, measured less than 1 cm in
posterior
diameter (over 2 cm circumferential pericardial effusion was
demonstrated prior to procedure).
4. Pericardial drain was left in place.
FINAL DIAGNOSIS:
1. Successful pericardiocentesis with reduction of pericardial
pressures.
2. Persistently elevated right atrial pressures suggestive of
diastolic
dysfunction and/or volume overload.
.
Echo ([**2163-7-31**]): post-pericardiocentesis
Conclusions:
There is mild symmetric left ventricular hypertrophy. There is
mild regional left ventricular systolic dysfunction with
inferior and inferolateral hypokinesis. Overall left ventricular
systolic function is mildly depressed. Right ventricular chamber
size and free wall motion are normal. There is a moderate to
large sized pericardial effusion. There is right ventricular
diastolic collapse/compression, consistent with impaired
fillling/tamponade physiology. Overall left ventricular systolic
function is mildly depressed (limited views so regional function
not adequately assessed). There is a very small residual
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
Echo ([**2163-8-1**]):
Conclusions:
There is symmetric left ventricular hypertrophy. Overall left
ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a small partially echo dense pericardial
effusion. There are no echocardiographic signs of tamponade.
Compared to the prior study of [**2163-7-31**], the pericardial effusion
now appears similar to slightly larger (views technically
suboptimal for comparison).
.
Chest Xray ([**2163-8-1**]):
IMPRESSION:
Lines and tubes, position as described.  Slight decrease in
width of cardiac contour, which may be due to partial drainage
of pericardial effusion.
.
Echo ([**2163-8-2**]):
Conclusions:
There is mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. There is a small
circumferential pericardial effusion without echocardiographic
evidence for tamponade physiology..
Compared with the prior study (images reviewed) of [**2163-8-1**],
the findings are similar.
.
Chest xray ([**2163-8-2**]):
Mildly enlarged cardiac silhouette is slightly smaller. There is
no pneumothorax.  Small bilateral pleural effusions unchanged.
Bibasilar atelectasis, greater on the left, has improved since
[**2163-8-1**], and worsened on the right.
.
Renal U/S ([**2163-8-6**]):
1. No evidence of hydronephrosis.
2. 2.6-cm cyst in the interpolar region of the left kidney.
.
Gradual improvement on CXR with CXR on [**2163-8-6**] showed:
Bibasilar atelectasis have improved. ET tube in standard
position. NG tube with tip in the stomach. Small right pleural
effusion is stable. Left subclavian vein catheter with tip in
the superior cavoatrial junction. Cardiomediastinal contour is
unchanged.
.
Discharge Labs:
[**2163-8-13**]  WBC-18.7  Hgb-10.6 Hct-31.6 MCV-89 Plt Ct-533
[**2163-8-13**]  Glucose-179 UreaN-26 Creat-6.5 Na-133 K-5.2 Cl-97
HCO3-22
          AnGap-20
[**2163-8-13**]  CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.3 Uric acid 6.4
.


Brief Hospital Course:
The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain s/p
cath with two stents placement in OM1 and mid-RCA, now developed
ARF on CRI, respiratory failure, and pneumonia/UTI.
.
1. CAD - Patient s/p cath with two stents placement in OM1 and
mid-RCA. Chest pain thought to be due to IMI. That night,
patient continued to have chest pain and pressure on the left
side of his chest and abdomen. Determined to have large
pericardial effusion with acute renal failure. ASA 325mg and
Plavix 75mg were continued.
.
2. Pericardial effusion - Following cath, chest xray showed a
widened mediastinum. Chest CT indicated a large pericardial
effusion. That night, patient had decreasing oxygen saturation
(85%) and the decision was made to intubate. The following
morning, a pulmonary artery (Swanz-Ganz) catheter was inserted
via the right internal jugular vein.  Hemondynamic measurements
indicated a PAP- 44/28, CO- 3.6, and CI -1.8.  Urine output
resumed following procedure.
.
3. Resp. failure/intubation --> Due to dropping O2 sat following
cath, patient was found to have large pericardial effusion,
small pleural effusion, and bibasilar atelectasis. The decision
was made to intubate. Post-pericardiocentesis patient was found
to have normal arterial blood gases. Since, he has been sedated,
restrained, and kept on CMV. Ongoing trials of CPAP+PS have
returned high RSBI values. On [**2163-8-6**], patient extubated without
difficulty and supplemented with 3L oxygen by nasal cannulae.
Patient encouraged to continue incentive spirometry. Since, he
has shown improved O2 sats requiring less supplemental oxygen.
Patient discharged wit O2 sat 97% on room air.
.
4. Pneumonia - After being intubated, patient developed
ventilator acquired pneumonia on [**2163-8-1**]. Empiric treatment with
vanc/cefipime was initiated. Sputum cultures indicated heavy
growth of S. Pneumo and some Psuedomonas. Patient then started
on Vanc/Zosyn. Psuedomonas determined to be pan-sensitive. S.
Pneumo sensitive to bactrim, vanc, levaquin. Central line
removed and tip cultured which showed no growth to date.  New
blood cultures were sent. All subsequent cultures are negative.
Patient continues to have elevated WBC. We d/c'ed zosyn on
[**2163-8-7**] and started cipro. On [**2163-8-8**], patient noted to have
decreasing WBC and afebrile past 24hrs. Patient given 10day
course of total antibiotics, including Vanc and Cipro.
.
5. UTI - On [**2163-8-3**], patient found to have abnormal UA. Culture
was positive to enterococcus. Patient started on Vanc.
Enterococcus sensitive to vanc. Vanc trough checked before
dialysis and dose given after dialysis. Patient treated for
10days.
.
6. ARF on CRI- Most likely contributed to recent motrin overuse
for pain, decreased CO, and contrast during cath on top of
already compromised renal function given poorly controlled
diabetes. After cath, patient noted to have elevated BUN (78),
Cr (6.6), and K (6.2) requiring emergent dialysis with CVVH to
his right femoral. Nephrocaps were started. Since
pericardiocentesis, patient has started producing minimal urine
output and noted decrease in BUN (30) and Cr (2.6). Due to
elevated right atrial filling pressures, patient will be
aggressively diuresed on CVVH. In consultation with nephrology
for short term hemodialysis, patient underwent insertion via IR
on left jugular tunneled catheter for hemodialysis. Dialysed
each day since [**2163-7-30**]. Nephrology adjusting electrolytes as
needed. Nephrocaps given each day.  On [**2163-8-5**], patient
developed anuria. Bladder scan indicated no urine in the
bladder. Renal u/s showed no evidence of hydronephrosis and
incidental 2.6-cm cyst in the interpolar region of the left
kidney. Per nephrology, patient will need a-v fistula for
short-term dialysis. Transplant surgery deferred placement of av
fistula for at least 1month. Instead, they indicated a desire
for a tunneled permcath placement. He went to the OR for
permcath insertion by transplant surgery on [**2163-8-12**]. At this
time, his temporary vascular catheter was removed. He was
discharged from the hospital on [**2163-8-13**] after dialysis. He is
scheduled to begin outpatient dialysis on tueday, [**2163-8-16**].
He will be on Tues/Thurs/Sat schedule.
.
7. Diarrhea - Onset occurred on [**2163-8-5**], patient noted to have
rapid watery, loose stools immediately after receiving tube
feeds. Unable to culture due to loose consistency and inability
to pass a rectal tube. Empiric treatment with flagyl for C.
Difficile initiated on [**2163-8-6**]. Cultures for C. diff have been
negative, but were taken after initiation of treatment. Flagyl
given for 5days, completed on [**2163-8-12**].
.
8. Anemia - Patient dropped hct to 25 on [**2163-7-30**] requiring
transfusion of 1 unit PRBCs. Since then, patient with stable
Hct/Hgb. On [**2163-8-2**], patient experienced drop in Hgb to 8, and
Hct to 24. He was transfused 2units PRBCs. Hgb/Hct now stable.
Per nephrology, Epo intiated. Hemoglobin and Hematocrit stable
at time of discharge.
.
9. HTN - Blood pressure meds held due to volume status with
elevated right filling pressures. While on CVVH, patient has
tolerated well with no episodes of hypotension. Patient
restarted on Metoprolol 12.5mg [**Hospital1 **]. Blood pressure unstable and
was titrated accordingly. Nephrology was consulted about
additional anti-hypertensives usage. They recommend BB, but will
reassess after more dialysis sessions.Advised to hold off on
ACEI because nephrology feels patient has chance to regain
kidney function after short course of dialysis. Continued
elevated blood pressures prompted addition of Norvasc 5mg.  He
was transitioned to metoprolol 100mg PO bid and norvasc 5mg PO
qday upon discharge.
.
10. Elevated LFTS/transaminitis - Patient noted to have
increasing ALT and AST until pericardiocentesis likely secondary
to shock liver (ischemic hepatitis). Since procedure, patient
noted to have decreasing ALT/AST. LFTs monitored daily.
.
11. DMT2 - Patient with complication of polyneuropathy and
likely nephropathy (Urine alb/Cr ratio in [**2158**] was 2800 (nl
0-30)) on nephrocap.  Blood sugar in the 300s, held oral
glycemic agents, initially on insulin drip overnight,and has
been switched to SSI with FS qid. Will continue neurontin for
polyneuropathy. Due to recent VAP, patient will be switched to
SSI and fixed scale. Elevated blood glucoses prompted adjustment
of Fixed Scale Insulin. Restarted on glipizide 10mg PO qd.
[**Last Name (un) **] center to be consulted on discharge. Before discharge,
patient was educated about insulin injections and blood glucose
monitoring.
.
12. Hyperlipidemia - On admission, we continued Lescol XL and
lofibria at home dose and checked lipid panel in the am
(fasting). Due to elevated LFTs (ALT and AST), patient was
discontinued off Lescol XL and Lofibria. Previously, patient
non-adherent to lipid therapy. LFTs monitored throughout
admission.LFTs shown to be decreasing. On [**2163-8-10**], we restarted
patient on Lipitor 10mg, and he was told to follow up with PCP
to titrate up as tolerated.
.
13. Nutrition - on regular, renal, diabetic, cardiac diet
.
14.  DVT prophylaxis - PPI, bowel regimen, subQ heparin
5000units tid. d/c'ed subq heparin once patient ambulating.
.
15. Activity - ambulating with walker, PT recommend home w/PT
.
16. Code - full code

Medications on Admission:
Lescol XL 80mg PO qday (not very compliant due to GI upset)
lofibra 200mg PO qday (not very compliant due to GI upset)
Glipizide 10mg PO qday
Avandia 8mg PO qday
Nephrocaps 1 cap PO qday (hasn't been taken them for three
months)
Uni-daily (multivit)1 tab PO qday
Lasix 20mg PO qday
Atenolol 50mg PO qday
Ativan 2mg PO bid
Neurontin 400mg PO qday
Ducolax


Discharge Medications:
1. Equipment
Rolling walker with seat and brakes

Diagnosis: Cardiac rehabilitation with chronic polyneuropathy
and balance deficit
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2*
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Insuline NPH
15 Units in the am and 10 units in the pm

Sliding scale insulin with humalog [**First Name8 (NamePattern2) **] [**Last Name (un) **] diabetic
recommendation
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1)  Injection
ASDIR (AS DIRECTED): with hemodialysis.
12. Lancets     Misc Sig: One (1)  Miscell.  four times a day.
Disp:*120 lancets* Refills:*2*
13. Truetrack Test     Strip Sig: One (1)  Miscell.  four times
a day.
Disp:*120 strips* Refills:*2*
14. Insulin Syringe 0.5cc/28G     Syringe Sig: One (1)  Miscell.
 five times a day.
Disp:*180 syringe* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
caregroup vna

Discharge Diagnosis:
Primary diagnosis
1)Inferior myocardial infarction s/p cath with cypher stents x2.

2)Acute renal failure on chronic renal insufficiency.
3)Respiratory failure
4)Pericardial effusion
5)Pneumonia
6)UTI
.
Secondary diagnosis
1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. Hypercholesterolemia


Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with

appropriate follow up.


Discharge Instructions:
Please call your doctor or seek medical attention in the ED if
you experience chest pain, shortness of breath, fever, chills,
sudden loss of vision, or any other concerning symptoms.
.
Please take all your medications exactly as prescribed and
described in this discharge paperwork.
We have made the following changes to your medications:
1) Please stop taking your Lescol XL and Lofibria. Instead we
have started you on Lipitor 10 mg once a day, please discuss
with your PCP and titrate up your Lipitor as tolerated.
2) Please start taking Aspirin 325 mg once a day.
3) Please start taking Plavix 75 mg once a day.
It is very important that you take ASA and Plavix everyday to
keep your the stents open in your heart.  DO NOT MISS A SINGLE
DOSE!
4) Please stop taking your Atenolol 50 mg. Instead, please take
Metoprolol 100mg by mouth twice a day and Norvasc 5 mg once a
day. Please discuss with your PCP or cardiologist to titrate up
your blood pressure medications.
5) Please stop taking Avandia. Instead, please take Glipizide XL
10mg once a day and insulin injections accordingly.
6) Please monitor your blood sugars  at least four times a day
with the glucometer as indicated by the nurse.
7) Please start taking Nephrocaps 1 capsule per day.
.
You have been scheduled for dialysis starting Tuesday, [**2163-8-16**] at 4pm at [**Location (un) **]. You will be on a Tues/Thurs/Sat
dialysis schedule.
Also, please follow up with the doctors we have listed below.

Followup Instructions:
[**Hospital **] Clinic: Tuesday, [**2163-8-16**] at 4pm ([**Location (un) **]).
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**]
          Date/Time:Monday,[**2163-8-29**] 8:40
PCP:      [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20670**], MD Phone: [**Telephone/Fax (1) 21993**], Date/Time:
friday,
          [**2163-8-26**] at 4:15pm
[**Last Name (un) **] Diabetes Ceneter:  Wednesday, [**2163-9-28**] at 10am.*
*They will call you at home if there is an earlier appointment
available. We recommend you take the earlier appointment if
possible.
.
Please call [**Hospital **] clinic [**Telephone/Fax (1) 3637**] to follow up with Dr.
[**First Name (STitle) 4102**] [**Name (STitle) 4090**](Nephrologist) for an appointment within a month of
discharge.
.
Please follow up with Dr. [**Last Name (STitle) **] (Cardiologist) by calling
[**Telephone/Fax (1) 4022**] within a month of discharge.



Completed by:[**2163-8-13**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute pericarditis in diseases classified elsewhere,Acute respiratory failure,Urinary tract infection, site not specified,Unspecified pleural effusion,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Background diabetic retinopathy,Other and unspecified complications of medical care, not elsewhere classified,Anemia in chronic kidney disease,Diarrhea'}


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: The pt is a 46 yo Spanish speaking only male with PMH of DM
(last HbA1C 9.2 on [**2162-10-28**]) complicated by polyneuropathy,
hypertension, hypercholesterolemia presented with chest pain.
Patient recently came back from a trip to [**Male First Name (un) 1056**] with his
wife, had an episode of diffuse chest pressure with radiation
and numbness to left arm which resolved without any intervention
about 2 weeks ago while on vacation.  The chest pressure and
pain returned two days ago, initially with diffuse chest pain
[**9-27**] radiating to neck, arms, back, and LLQ of abdomen, but
this morning the pain was more localized to the left sided of
his chest and LLQ of abdomen with radiation to the back. He has
been taking Motrin 600mg PO q6h prn for his pain, which didn't
help.  The pain was associated with nausea and vomiting,
diarrhea, and occasional chills, no fever or diaphoresis.  Per
daughter and wife, he also had recent sick contact: his
granddaughter was having flu-like symptoms with fever, headache,
N/V/D.  Because of his unresolving chest pain, he came the [**Hospital1 18**]
ED where ECG was obtained which showed 1-2mm ST elevation in the
inferior leads.  Decision was made to take him to the cath lab
directly without his lab results.
.
In the Cath Lab: he was found to have normal LMCA, multiple
serial 70% stenosis in the LAD, Lcx diffuse disease: 90% OM1
stented, 70% OM2; 90% Mid RCA stented, 60% distal RCA
unintervened.  He was brought to [**Hospital1 1516**] service initially and
found to have a Cr of 6.1 (baseline 2.4), and K of 6.4, he was
transferred the CCU service for further management of his
cardiac and renal issues.  On presentation to CCU, he is
hemodynamically stable, he felt like he needs to urinate, but
really can't when he tries, and he has been have these symptoms
for more than half a year.  Foley cath was placed, and he was
started on dialysis.

MEDICAL HISTORY: 1. Diabetes complicated by polyneuropathy since the age of 19;
Last A1C was 9.2
2. Hypertension
3. hypercholesterolemia
4. schizophrenia diagnosed many years ago per family, but never
took any meds.
5. Carpal tunnel syndrome.
6. Depression (not on meds)
.

MEDICATION ON ADMISSION: Lescol XL 80mg PO qday (not very compliant due to GI upset)
lofibra 200mg PO qday (not very compliant due to GI upset)
Glipizide 10mg PO qday
Avandia 8mg PO qday
Nephrocaps 1 cap PO qday (hasn't been taken them for three
months)
Uni-daily (multivit)1 tab PO qday
Lasix 20mg PO qday
Atenolol 50mg PO qday
Ativan 2mg PO bid
Neurontin 400mg PO qday
Ducolax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission PE:
VS: T 95.1, BP 132/77 (equal on both sides), BP 79, RR 25, 97%
on 2L NS
GEN: lying flat, speaks no English, NAD
HEENT: PERRL. MMM. OP clear. no JVD and no bruits
HEART: RRR no m/r/g. distant heart sounds, no m/r/g appreciated.

FAMILY HISTORY: Significant for myocardial infarction in his father at the age
of 49.

SOCIAL HISTORY: The patient does not smoke and he does not drink alcohol. He
lives with his wife. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute pericarditis in diseases classified elsewhere,Acute respiratory failure,Urinary tract infection, site not specified,Unspecified pleural effusion,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia,Polyneuropathy in diabetes,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Background diabetic retinopathy,Other and unspecified complications of medical care, not elsewhere classified,Anemia in chronic kidney disease,Diarrhea'}
