CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 57 YOM with history of 3VD s/p Quintuple CABG in [**2155-6-14**] and
redo CABG in [**4-/2157**] and PCI in [**Month (only) 404**] of this year, HTN, DM,
and CKD on Tu,[**Month (only) 5929**], Sunday [**Hospital **] transferred from OSH ED for
fever, SOB and EKG changes concerning for ischemia.
.
Brifely he was at his routine HD appointment yesterday and noted
to have fever to 102. He endorses URI type symptoms for the last
several days. HD center opted to forgoe dialysis and he was sent
to OSH ED for evaluation. En route he developed hypotension and
SSCP with radiation to his right arm. EKG on arrival to the OSH
ED showed.... STD in v2-v6 as well as elevations in aVR. There
was some question of elevation in II and III. He was started on
vancomycin, heparin, and nitro gtt and transferred to [**Hospital1 18**] out
of concern for ACS. He was hypotensive en route and started on
levophed.
.
On arrival to [**Hospital1 18**] ED. Pain free. Off levophed, nitro. He
reports his baseline SBP is in the 90's and falls as low as the
70's on HD. His levophed, and nitro gtt were DC'd. His CXR did
not appear to be overly congested and he was lying flat with no
hypoxemia. Bedside Echo did not show any wall motion
abnormality. ED felt him to be somewhat dry and began to give
him a 500 cc bolus.
.
Labs were notable for an OSH trop of 0.3, lactate of 1.2. [**Hospital1 18**]
enzymes ar pending.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION
VS: 104/65 P96 98% O2 on 2L NC
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: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies
Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Acute upper respiratory infections of unspecified site,Unspecified viral infection,End stage renal disease,Secondary hyperparathyroidism (of renal origin),Chronic systolic heart failure,Chronic total occlusion of coronary artery,Hyperpotassemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Unspecified essential hypertension,Polyneuropathy in diabetes,Unspecified cataract,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Aortocoronary bypass status,Renal dialysis status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of insulin
Comp-oth cardiac device,Subendo infarct, initial,Acute uri NOS,Viral infection NOS,End stage renal disease,Sec hyperparathyrd-renal,Chr systolic hrt failure,Chr tot occlus cor artry,Hyperpotassemia,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Hypertension NOS,Neuropathy in diabetes,Cataract NOS,Hypothyroidism NOS,Pure hypercholesterolem,Periph vascular dis NOS,Aortocoronary bypass,Renal dialysis status,Abn react-artif implant,Long-term use of insulin
Admission Date:  [**2157-7-18**]              Discharge Date:   [**2157-7-23**]

Date of Birth:  [**2099-9-15**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 28286**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
[**2157-7-19**] cardiac catheterization, no interventions
[**2157-7-21**] cardiac catheterization, drug eluding stent placed to
left circumflex artery and left main coronary artery at takeoff
of left circumflex

History of Present Illness:
57 YOM with history of 3VD s/p Quintuple CABG in [**2155-6-14**] and
redo CABG in [**4-/2157**] and PCI in [**Month (only) 404**] of this year, HTN, DM,
and CKD on Tu,[**Month (only) 5929**], Sunday [**Hospital **] transferred from OSH ED for
fever, SOB and EKG changes concerning for ischemia.
.
Brifely he was at his routine HD appointment yesterday and noted
to have fever to 102. He endorses URI type symptoms for the last
several days. HD center opted to forgoe dialysis and he was sent
to OSH ED for evaluation. En route he developed hypotension and
SSCP with radiation to his right arm. EKG on arrival to the OSH
ED showed.... STD in v2-v6 as well as elevations in aVR. There
was some question of elevation in II and III. He was started on
vancomycin, heparin, and nitro gtt and transferred to [**Hospital1 18**] out
of concern for ACS. He was hypotensive en route and started on
levophed.
.
On arrival to [**Hospital1 18**] ED. Pain free. Off levophed, nitro. He
reports his baseline SBP is in the 90's and falls as low as the
70's on HD. His levophed, and nitro gtt were DC'd. His CXR did
not appear to be overly congested and he was lying flat with no
hypoxemia. Bedside Echo did not show any wall motion
abnormality. ED felt him to be somewhat dry and began to give
him a 500 cc bolus.
.
Labs were notable for an OSH trop of 0.3, lactate of 1.2. [**Hospital1 18**]
enzymes ar pending.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

2. CARDIAC HISTORY:
- CABG:
-[**6-/2155**]  VFib arrest with CABG at [**Hospital1 112**] for 3vd, 5vessel-CABG with

 LIMA to LAD double touchdown with endarterectomy from D1 to
 apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA
-[**4-/2157**]  CABG Redo sternotomy and coronary artery bypass graft
x3, saphenous vein graft to obtuse marginal 1, 2 and 3.
- PERCUTANEOUS CORONARY INTERVENTIONS:
[**2-/2157**] PCI POBA to 70% L main occulsion, POBA 90% in LAD, DES
placed to L circ for 80% prox with 60% mid occlusion
Repeat cath [**5-2**] showed instent restenosis of L circ (extending
to L main)
- PACING/ICD:  None
3. OTHER PAST MEDICAL HISTORY:
- ESRD on hemodialysis (at Quality Care [**Location (un) **], Tu,[**Last Name (LF) 5929**],[**First Name3 (LF) **]
overnight dialysis)
- Diabetes mellitus with renal complications
- Neuropathy
- Retinopathy
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
- Cataract
- Charcot foot due to diabetes mellitus
- Hypothyroidism
- Hyperlipidemia
- Obesity s/p Lap Band ([**2154**])
- Hyperparathyroidism [**3-17**] renal
- Renal osteodystrophy
- Pulmonary Nodule (Solitary)
- History of Colonic Adenoma
- Left arm fistula
- s/p Lap Band ([**2154**])


Social History:
Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies


Family History:
Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.


Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 104/65 P96 98% O2 on 2L NC
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
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: Slightly decreased breathsounds at the bilateral bases.
No crackles or edema.
ABDOMEN: Soft, NTND +BS
NEURO: AAOx3
PULSES:
Right:  DP 2+
Left:  DP 2+

Physical Exam on Discharge:
afebrile, BP 90s-110s/60s
exam unchanged

Pertinent Results:
ADMISSION LABS:
[**2157-7-18**] 08:50AM BLOOD WBC-9.0# RBC-3.66* Hgb-11.8* Hct-35.6*
MCV-97 MCH-32.2* MCHC-33.1 RDW-16.3* Plt Ct-160
[**2157-7-18**] 08:50AM BLOOD Neuts-90.2* Lymphs-5.2* Monos-3.0 Eos-0.4
Baso-1.1
[**2157-7-18**] 08:50AM BLOOD PT-12.9* PTT-54.9* INR(PT)-1.2*
[**2157-7-18**] 08:50AM BLOOD Glucose-176* UreaN-66* Creat-12.7*#
Na-136 K-6.0* Cl-98 HCO3-21* AnGap-23*
[**2157-7-18**] 08:50AM BLOOD Calcium-7.7* Phos-5.1* Mg-2.6

CARDIAC ENZYMES:
[**2157-7-18**] 08:50AM BLOOD CK-MB-21* MB Indx-5.8
[**2157-7-18**] 08:50AM BLOOD cTropnT-1.60*
[**2157-7-18**] 03:00PM BLOOD CK-MB-23* MB Indx-5.1 cTropnT-3.71*
[**2157-7-18**] 11:12PM BLOOD CK-MB-11* cTropnT-5.66*
[**2157-7-20**] 04:23AM BLOOD CK-MB-4
[**2157-7-20**] 09:11AM BLOOD CK-MB-4 cTropnT-3.31*

DISCHARGE LABS:
[**2157-7-23**] 05:49AM BLOOD WBC-5.1 RBC-3.30* Hgb-10.3* Hct-32.5*
MCV-99* MCH-31.2 MCHC-31.6 RDW-16.0* Plt Ct-148*
[**2157-7-23**] 05:49AM BLOOD PT-11.2 PTT-31.7 INR(PT)-1.0
[**2157-7-23**] 05:49AM BLOOD Glucose-63* UreaN-36* Creat-8.5*# Na-140
K-4.4 Cl-100 HCO3-29 AnGap-15
[**2157-7-20**] 09:11AM BLOOD ALT-35 AST-55* CK(CPK)-134 AlkPhos-51
TotBili-0.4
[**2157-7-20**] 09:11AM BLOOD Lipase-43
[**2157-7-23**] 05:49AM BLOOD Calcium-7.6* Phos-4.4 Mg-2.4
[**2157-7-18**] 03:00PM BLOOD TSH-0.13*

MICROBIOLOGY:
[**2157-7-18**] BLOOD CULTURE X 4 NEGATIVE
[**2157-7-19**] CDIFF STOOL NEGATIVE

REPORTS:
[**2157-7-18**] Radiology CHEST (PORTABLE AP)
The lungs are clear.  There is no focal consolidation to suggest

pneumonia.  Heart size is enlarged, but unchanged.  Bibasilar
opacities
represent atelectasis in the setting of low lung volumes.
Sternotomy wires and CABG clips are noted.  There is no
pneumothorax.  No definite pleural effusions are seen

[**2157-7-19**] ECHO:
This study was compared to the prior study of [**2157-7-5**].
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Mild regional LV systolic dysfunction. No LV mass/thrombus. No
resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. No MS. Mild to moderate ([**2-14**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: Very small pericardial effusion. No
echocardiographic signs of tamponade.

Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with inferior, infero-lateral, distal
LV/apical hypokinesis suggested. No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The ascending aorta is mildly dilated.
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
([**2-14**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is a very small pericardial
effusiOn. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2157-7-5**], no
change.

[**2157-7-19**] CARDIAC CATH;
1. Selective coronary angiography of this co dominant system
revealed
three vessel native coronary artery disease. The LMCA had a 90%
distal
instent restenosis. The LAD had 50% ostial disease and 95%
stenosis
after D1. D1 was 100% occluded. The Lcx had 99% proximal instent

restenosis. The mid Lcx had 80% stenosis and the OM1 was 100%
occluded.
The RCA was 100% totally occluded proximally.
2. Limited resting hemodynamics revealed borderline low systemic
blood
pressure of 80/50 mmHg that is close to patient's baseline.
Gentle IVF
were given since HD performed earlier that day.
3. Saphenous vein graft arteriography showed the SVG-RCA to be
widely
patent. The SVG-OM1 had mild irregularity only and the proximal
stent
was widely patent. There was 60% diffuse disease in the OM1
proximal and
distal to touchdown site. The jump segments of this graft to OM2
and OM3
(L. lpl) are flush occluded (similar to prior angiography
5/[**2157**]). There
is a jump segment (from first bypass surgery) from OM1 to Om2
which is
widely patent.
4. Arterial conduit angiography was deferred as LIMA-LAD known
patent
and competative flow seen in distal native LAD.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG-RCA, patent SVG-OM1 with occluded jump segment.
3. PAtent proximal SVG-OM1 stent.
4. Borderline low blood pressure.
5. Demand ischemia likely due to limited flow through jump
segment from
om1-om2 with intervening disease between anastamosis sites.
6. Medical management, however if ongoing ischemia or chest
pain, would
consider PCI of native LMCA-Lcx to improve perfusion to distal
codominant Lcx system.

[**2157-7-21**] CARDIAC CATH
1. Selective coronary angiography in this right dominant system
demonstrated an 80% distal LMCA stenosis, a 99% ostial Cx
stenosis (both
in-stent restenosis) and a seperate 80% stenosis in the mid Cx.
2. Selective arterial conduit angiography revealed a widely
patent LIMA
to LAD/D1. There is an occlusion of the distal LAD beyonf the
touchdown
of the LIMA.
3. Limited resting hemodynamics revealed a central aortic
pressure of
89/54 mmHg.
4. Successful PTCA and stenting of the mid Cx with a 3.0x16mm
PROMUS
ELEMENT stent which was postdilated to 3.25mm. Final angiography

revealed no residual stenosis, no angiographically apparent
dissection
and TIMI III flow (see PTCA comments).
5. [**Name (NI) 9927**] PTCA and stenting of the LMCA and proximal Cx with
a
3.5x24mm PROMUS ELEMENT stent which was postdilated proximally
to 4.5mm
and distally to 4.0mm. Final angiography revealed no residual
stenosis,
no angiographically apparent dissection and TIMI III flow (see
PTCA
comments).

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the mid Cx with a DES.
3. Successful PTCA and stenting of the LMCa and proximal Cx with
a DES.

Brief Hospital Course:
Mr. [**Known lastname **] is a 57 year old male with history of diabetes,
hypertension, and coronary artery disease (CAD) status post CABG
x 2 with 8 total bypasses as well as recent PCI 2 weeks prior to
admission who was transferred from OSH with chest pain and
dynamic EKG changes in the setting of fever, hyperkalemia and
hypotension.  He was  admitted to the CCU for dialysis and
cardiac catheterization and recieved 2 drug eluding stents (DES)
to his left circumflex and left main coronary arteries.

# Coronary artery disease (CAD): Patient with extensive known
CAD. Patient was started on heparin drip at OSH and this was
continued on admission. He was also continued on atorvastatin 80
mg daily, ASA 325 mg daily, clopidogrel 75 mg daily and
metoprolol 12.5mg [**Hospital1 **]. Notably, he is not on an ACEI. He
underwent cardiac catheterization on [**2157-7-19**] which showed 3
vessel disease but he was not stented at this time because it
was felt that ST changes at OSH could represent acute coronary
syndrome vs demand ischemia from fever, hypotension and
tachycardia.  He continued to have chest pain however, so he
returned to the cath lab on [**2157-7-21**] and had 2 DES placed.  One in
his left circumflex and one in his left main, these jailed the
LAD--it is now only supplied by the LIMA graft.  After the
stents were placed, he had resolution of his chest pain.  His
medications were not changed except aspirin was decreased to 81
mg daily.

# Chronic systolic heart failure (sCHF): Patient was not grossly
volume overloaded on admission with no edema on CXR or exam.
Last known EF of 45% in [**Month (only) 116**] of this year.
Fluid status is managed with hemodialysis as patient does not
make urine.  Recieved HD while he was an inpatient, continued on
metoprolol 12.5 mg [**Hospital1 **], no diuretics or ACEi given the renal
impairment.

# Fever: Patient presented with fever at dialysis and OSH after
developing sore throat and cough. His family had similar
symptoms raising concern for viral upper respiratory infection.
However, he was started on empiric vancomycin and zosyn at OSH
for presumed healthcare assoc pneumonia (HCAP). Zosyn was
transitioned to cefepime on transfer. CXR showed no evidence of
pneumonia and cultures grew nothing for 48 hours, Cdiff
negative.  Thus, all antibiotics were discontinued and he did
not have any additional fevers.

CHRONIC PROBLEMS:
# [**Name2 (NI) **] stage renal disease (ESRD): Patient presented with mild
volume overload and hyperkalemia in setting of missed
hemodialysis (HD). He underwent urgent dialysis morning of
admission and was then continued on intermittent HD.  He
continued his sevalamer with meals and nephrocaps daily.
# Diabetes mellitus, type 2 (DMT2): Continued home regimen of
long acting insulin 10 units qam and 20 units qpm with sliding
scale coverage.
# Hyperlipidemia (HLD): Continued Atorvastatin 80 mg daily.
# Hypothyroidism: Continued thyroxine 300 mcg 5x/week.  TSH was
0.13.

TRANSITIONAL ISSUES:
- TSH was low, his levothyroxine dose should be discussed with
PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] dialysis
- Consider adding ACEi for heart failure benefit even though he
has renal failure because this will not damage the kidneys
further

Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. insulin aspart 100 unit/mL Insulin Pen Sig: per sliding scale

 Subcutaneous three times a day.
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
7. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO 5X/WEEK

(MO,TU,WE,TH,FR).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
packets PO TID (3 times a day).
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. NPH insulin human recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous as directed: 10 units qAM, 20-30
units qPM.

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: as directed units Subcutaneous twice a day: 10 units at
breakfast, 20 units at bedtime.
6. insulin lispro 100 unit/mL Insulin Pen Sig: as directed units
Subcutaneous three times a day: per sliding scale.
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
8. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
packets PO three times a day: with meals.
11. aspirin 81 mg Tablet, Effervescent Sig: One (1) Tablet,
Effervescent PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY DIAGNOSIS
coronary artery disease
viral upper respiratory infection

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

Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted to the hospital because you had some chest
pain while you had fevers.  Your fevers were from a viral upper
respiratory infection and you were already getting better from
that.  You underwent a cardiac cath which showed that your chest
pain likely came from some blockages to blood flow. You had
stents put in the arteries of your heart to open them up and we
expect your chest pain to be resolved.

Medication changes made:
We decreased your aspirin to a baby aspirin (81mg a day).

You should keep all of the follow-up appointments listed below.
Bring your medications to each appointment so your doctors [**Name5 (PTitle) **]
update their records and adjust doses as needed.

It was a pleasure taking care of you in the hospital!

Followup Instructions:
Name:[**Name6 (MD) 74722**] [**Name8 (MD) **],MD
Specialty: Priamry Care
Location: [**Location (un) 2274**]-[**Location (un) **]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17465**]
When: [**Last Name (LF) 766**],[**8-1**] at 10:00am

Name:[**Name6 (MD) 88768**] [**Last Name (NamePattern4) 90369**], MD
Specialty: Cardiology
Location: [**Hospital1 641**]
Address: 111 [**Doctor Last Name **] DR, [**Location (un) **],[**Numeric Identifier 34404**]
Phone: [**Telephone/Fax (1) 56771**]
When: [**Last Name (LF) 2974**], [**8-5**] a 11:00am

Department: HEMODIALYSIS
When: SATURDAY [**2157-7-23**] at 7:30 AM
{'Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Acute upper respiratory infections of unspecified site,Unspecified viral infection,End stage renal disease,Secondary hyperparathyroidism (of renal origin),Chronic systolic heart failure,Chronic total occlusion of coronary artery,Hyperpotassemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Unspecified essential hypertension,Polyneuropathy in diabetes,Unspecified cataract,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Aortocoronary bypass status,Renal dialysis status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of insulin'}


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: 57 YOM with history of 3VD s/p Quintuple CABG in [**2155-6-14**] and
redo CABG in [**4-/2157**] and PCI in [**Month (only) 404**] of this year, HTN, DM,
and CKD on Tu,[**Month (only) 5929**], Sunday [**Hospital **] transferred from OSH ED for
fever, SOB and EKG changes concerning for ischemia.
.
Brifely he was at his routine HD appointment yesterday and noted
to have fever to 102. He endorses URI type symptoms for the last
several days. HD center opted to forgoe dialysis and he was sent
to OSH ED for evaluation. En route he developed hypotension and
SSCP with radiation to his right arm. EKG on arrival to the OSH
ED showed.... STD in v2-v6 as well as elevations in aVR. There
was some question of elevation in II and III. He was started on
vancomycin, heparin, and nitro gtt and transferred to [**Hospital1 18**] out
of concern for ACS. He was hypotensive en route and started on
levophed.
.
On arrival to [**Hospital1 18**] ED. Pain free. Off levophed, nitro. He
reports his baseline SBP is in the 90's and falls as low as the
70's on HD. His levophed, and nitro gtt were DC'd. His CXR did
not appear to be overly congested and he was lying flat with no
hypoxemia. Bedside Echo did not show any wall motion
abnormality. ED felt him to be somewhat dry and began to give
him a 500 cc bolus.
.
Labs were notable for an OSH trop of 0.3, lactate of 1.2. [**Hospital1 18**]
enzymes ar pending.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM ON ADMISSION
VS: 104/65 P96 98% O2 on 2L NC
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: Father with kidney disease. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death. Uncle
with cancer, NOS.

SOCIAL HISTORY: Lives in [**Location **] with his wife and sister-in-law.  [**Name (NI) **] 3
children who live in the area.  Retired 3 years ago.  Since
[**4-/2157**] CABG, has been back to his baseline after (except
lifting), but he is not very active at baseline.
Tobacco history: 30 pack year history, quit at time of CABG in
[**2155**].
ETOH: never
Illicit drugs: denies 

### Response:
{'Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Acute upper respiratory infections of unspecified site,Unspecified viral infection,End stage renal disease,Secondary hyperparathyroidism (of renal origin),Chronic systolic heart failure,Chronic total occlusion of coronary artery,Hyperpotassemia,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Unspecified essential hypertension,Polyneuropathy in diabetes,Unspecified cataract,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Aortocoronary bypass status,Renal dialysis status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Long-term (current) use of insulin'}
