CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: The patient is 68 y/o M w/hx of CAD s/p MI in [**2186**], HTN,
hyperlipidemia who is transferred from [**Hospital3 **] for STEMI. Pt
was first admitted on [**2195-1-14**] and underwent L3-L5 laminectomy,
fusion, foraminotmy, and durotomy with bone autograft.
Posteroperatively, the patient developed chest pain, which was
treated with IV NTGL, morphine, and metoprolol. The patient was
treated with these conservative measures, and given resolution
of chest pain and contraindication of anticoagulation, cardiac
catheterization was deffered. Cardiac markers were cycled, and
CK peaked on [**2195-1-15**] at 5021, trop 70, and has trended down
since. He has remained chest pain free since.
On [**2195-1-16**], the patient went into atrial fibrillation with a
rapid ventricular response of 144, and the patient was
transfered to the NEBH CCU. IV lopressor was administered,
without effect. The patient was started on a diltiazem gtt, with
improvement of HR control to 90s-120s. The patient remained
asymptomatic and hemodynamically stable throughout. He was
managed with a dilt gtt, PO lopressor and amioderone. At that
time, heparin gtt was also started. The patient converted to
sinus rhythm, and the dilt gtt was stopped. On the morning of
transfer, the patient went back into afib again with HRs in the
140 and Dilt gtt was restarted. Lopressor increased to 200mg PO
BID and amio to 400mg PO BID. Pt was reportedly noted to have
long pauses and ? of new LBBB, and had transvenous pacer wire
placed on [**2195-1-16**].
On the night prior to transfer, the patient spiked temp to
101.6, despite RTC tylenol. CXR was obtained and UA and culture
was taken. Despite a normal WBC on admission, the patient has
had a leukocytosis since [**1-14**] of 26.5. He has not received
antibiotics and no blood cultures were drawn.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**5-/2186**]: mid LCx with BMS
[**3-/2192**]: PCI to RCA and LAD, likely DES following + ETT
-PACING/ICD: transvenous pacer placed [**2195-1-16**] at NEBH
3. OTHER PAST MEDICAL HISTORY:
.
s/p spine surgery w/ laminectomy, fusion, and instrumentation

MEDICATION ON ADMISSION: Home Medications-
Simvastatin 40mg dialy
Folic acid 1mg daily
Metoprolol 100mg qam and 50mg qpm
Niaspan 500mg daily
aspirin 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=98.7 BP= 95/51 HR= 78 RR= 25 O2 sat= 93% on 50% O2
GENERAL: WDWN male, tachypnic and diaphoretic. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Quit smoking:
-ETOH: 2 glasses of wine daily.
-Illicit drugs: No history of illicit drugs
.
The patient is married with four children He is a retired
construction worker.
Acute myocardial infarction of anterolateral wall, initial episode of care,Acute systolic heart failure,Paralytic ileus,Acute kidney failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Leukocytosis, unspecified,Hypoxemia,Pure hypercholesterolemia,Long-term (current) use of anticoagulants
AMI anterolateral, init,Ac systolic hrt failure,Paralytic ileus,Acute kidney failure NOS,Atrial fibrillation,Crnry athrscl natve vssl,Hypertension NOS,Leukocytosis NOS,Hypoxemia,Pure hypercholesterolem,Long-term use anticoagul
Admission Date:  [**2195-1-17**]              Discharge Date:   [**2195-1-28**]

Date of Birth:  [**2126-3-22**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
Cardiac catheterization

History of Present Illness:
The patient is 68 y/o M w/hx of CAD s/p MI in [**2186**], HTN,
hyperlipidemia who is transferred from [**Hospital3 **] for STEMI. Pt
was first admitted on [**2195-1-14**] and underwent L3-L5 laminectomy,
fusion, foraminotmy, and durotomy with bone autograft.
Posteroperatively, the patient developed chest pain, which was
treated with IV NTGL, morphine, and metoprolol. The patient was
treated with these conservative measures, and given resolution
of chest pain and contraindication of anticoagulation, cardiac
catheterization was deffered. Cardiac markers were cycled, and
CK peaked on [**2195-1-15**] at 5021, trop 70, and has trended down
since. He has remained chest pain free since.
On [**2195-1-16**], the patient went into atrial fibrillation with a
rapid ventricular response of 144, and the patient was
transfered to the NEBH CCU. IV lopressor was administered,
without effect. The patient was started on a diltiazem gtt, with
improvement of HR control to 90s-120s. The patient remained
asymptomatic and hemodynamically stable throughout. He was
managed with a dilt gtt, PO lopressor and amioderone. At that
time, heparin gtt was also started. The patient converted to
sinus rhythm, and the dilt gtt was stopped. On the morning of
transfer, the patient went back into afib again with HRs in the
140 and Dilt gtt was restarted. Lopressor increased to 200mg PO
BID and amio to 400mg PO BID. Pt was reportedly noted to have
long pauses and ? of new LBBB, and had transvenous pacer wire
placed on [**2195-1-16**].
On the night prior to transfer, the patient spiked temp to
101.6, despite RTC tylenol. CXR was obtained and UA and culture
was taken. Despite a normal WBC on admission, the patient has
had a leukocytosis since [**1-14**] of 26.5. He has not received
antibiotics and no blood cultures were drawn.

On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**5-/2186**]: mid LCx with BMS
[**3-/2192**]: PCI to RCA and LAD, likely DES following + ETT
-PACING/ICD: transvenous pacer placed [**2195-1-16**] at NEBH
3. OTHER PAST MEDICAL HISTORY:
.
s/p spine surgery w/ laminectomy, fusion, and instrumentation


Social History:
-Tobacco history: Quit smoking:
-ETOH: 2 glasses of wine daily.
-Illicit drugs: No history of illicit drugs
.
The patient is married with four children He is a retired
construction worker.


Family History:
No family history of early MI, otherwise non-contributory.


Physical Exam:
VS: T=98.7 BP= 95/51 HR= 78 RR= 25 O2 sat= 93% on 50% O2
GENERAL: WDWN male, tachypnic and diaphoretic. 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 JVP at mandible.
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: Could not assess as did not want to alter patient's
position [**3-15**] pain. Per nursing, crackles at bases b/l.
ABDOMEN: Soft, mildy tense, and distended. Decreased bowel
sounds. =
EXTREMITIES: No c/c/e. No femoral bruits.
BACK: Dressin in place, C/D/I, JP drain in place.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
Laboratory studies:
[**2195-1-17**] 08:51PM BLOOD WBC-21.6* RBC-3.29* Hgb-10.8* Hct-30.7*
MCV-93 MCH-33.0* MCHC-35.3* RDW-12.4 Plt Ct-251
[**2195-1-18**] 05:23AM BLOOD WBC-20.4* RBC-3.10* Hgb-10.1* Hct-28.8*
MCV-93 MCH-32.4* MCHC-34.9 RDW-13.1 Plt Ct-232
[**2195-1-24**] 04:16AM BLOOD WBC-18.7* RBC-2.94* Hgb-9.5* Hct-27.2*
MCV-92 MCH-32.3* MCHC-34.9 RDW-13.4 Plt Ct-439
.
[**2195-1-17**] 08:51PM BLOOD Neuts-87.7* Lymphs-7.1* Monos-4.8 Eos-0.3
Baso-0.1
.
[**2195-1-17**] 08:51PM BLOOD PT-14.6* PTT-42.2* INR(PT)-1.3*
[**2195-1-24**] 04:16AM BLOOD PT-18.8* PTT-107.2* INR(PT)-1.7*
.
[**2195-1-17**] 08:51PM BLOOD Glucose-142* UreaN-26* Creat-1.4* Na-132*
K-4.5 Cl-99 HCO3-26 AnGap-12
[**2195-1-18**] 05:23AM BLOOD Glucose-143* UreaN-31* Creat-1.6* Na-134
K-4.0 Cl-99 HCO3-27 AnGap-12
[**2195-1-19**] 04:12PM BLOOD Glucose-141* UreaN-29* Creat-1.4* Na-138
K-3.7 Cl-98 HCO3-33* AnGap-11
[**2195-1-22**] 04:28AM BLOOD Glucose-178* UreaN-32* Creat-2.2* Na-133
K-3.5 Cl-95* HCO3-28 AnGap-14
[**2195-1-24**] 04:16AM BLOOD Glucose-140* UreaN-40* Creat-2.8* Na-134
K-3.9 Cl-98 HCO3-27 AnGap-13
.
[**2195-1-17**] 08:51PM BLOOD CK-MB-7 cTropnT-2.21* proBNP-[**Numeric Identifier **]*
[**2195-1-17**] 08:51PM BLOOD Calcium-9.2 Phos-1.6* Mg-2.3
[**2195-1-20**] 04:53AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.9
[**2195-1-24**] 04:16AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.4
.
[**2195-1-18**] 06:16AM BLOOD Type-ART Temp-37.0 pO2-115* pCO2-37
pH-7.47* calTCO2-28 Base XS-4
.
[**2195-1-22**] 10:56PM BLOOD Type-ART pO2-84* pCO2-37 pH-7.50*
calTCO2-30 Base XS-4
[**2195-1-18**] 06:16AM BLOOD Lactate-1.1
[**2195-1-18**] 06:16AM BLOOD freeCa-1.27
.
Urine studies:
.
[**2195-1-18**] 03:27PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2195-1-18**] 03:27PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2195-1-18**] 03:27PM URINE RBC-6* WBC-1 Bacteri-FEW Yeast-NONE Epi-0
[**2195-1-18**] 03:27PM URINE CastHy-25*
[**2195-1-22**] 06:49AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2195-1-22**] 06:49AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2195-1-22**] 06:49AM URINE RBC-21-50* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
.
[**2195-1-18**] 03:27PM URINE Hours-RANDOM UreaN-422 Creat-98 Na-30
[**2195-1-22**] 06:49AM URINE Hours-RANDOM UreaN-248 Creat-88 Na-42
[**2195-1-23**] 09:30AM URINE Hours-RANDOM UreaN-270 Creat-95 Na-35
.
Microbiology:
.
BCx, UCx, MRSA screen- were all negative from [**1-18**].
BCx [**1-20**], Urinary Leginella [**1-20**], Ifnluenza nasal washing [**1-20**]
Stool C. Diff [**1-22**] were all negative.
Catheter tip Cx [**1-20**] was negative.
Sputum smear and Cx were persistently contaminated w/ epithelial
cells.
.
Imaging/Stdies:
.
Echo [**1-17**] - The left atrium is mildly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
systolic dysfunction with severe hypokinesis of the distal half
of the anterior septum and anterior walls. The apex is akinetic
and mildly aneurysmal. The remaining segments contract well
(LVEF= 35-40 %). No thrombus is seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild [1+] mitral
regurgitation is seen. There is pulmonary artery systolic
pressure is high normal. There is an anterior space which most
likely represents a fat pad.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (mid-LAD distribution).
Mild mitral regurgitation.
.
ECG - [**1-17**]
Atrial fibrillation with moderate ventricular response and one
ventricularly
paced beat. There is anterolateral ST segment elevation
suggestive of
acute myocardial infarction. No previous tracing available for
comparison.
Clinical correlation is suggested.
TRACING #1


Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 0 98 412/417 0 -29 4
.
CXR [**1-17**]
.
Temporary pacer lead traverses the pulmonary outflow tract, but
loops in the
main pulmonary artery and probably ends in the upper right
ventricle. Heart
is moderately to severely enlarged. Pulmonary vasculature and
mediastinal
veins are mildly engorged, but there is no edema or appreciable
pleural
effusion. No pneumothorax or mediastinal widening.
.
KUB [**1-17**]:
Supine and left decubitus views of the abdomen show no
pneumoperitoneum. There is gas in the colon, but gas distending
the entire
small bowel is disproportionately larger, sometimes present with
adynamic
ileus, which is the most likely diagnosis. Stabilization device
spans the
lower lumbar and lumbosacral levels of the spine.
.
CXR [**1-18**]-
Small left pleural effusion is new. There might be a region of
developing
consolidation in the infrahilar left lower lobe, but this area
subsequently
clears on chest radiographs performed at 8:15 a.m. available at
the time of
this dictation and reported separately. No pneumothorax.
Moderate
cardiomegaly and mediastinal vascular engorgement unchanged.
Pulmonary
vasculature unremarkable, right lung clear.

As before, the transjugular temporary pacer lead loops in the
main pulmonary
artery and returns to the upper right ventricle.
.
ECG [**1-19**] -
Atrial fibrillation with controlled ventricular response. Right
bundle-branch
block. Compared to the previous tracing of [**2195-1-18**] the rate is
slower.


Read by: [**Last Name (LF) **],[**First Name3 (LF) **]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 0 140 438/467 0 -34 95
.
CXR [**1-20**]:
FINDINGS: In comparison with the study of [**1-19**], the right
central catheter
has been removed. Nasogastric tube remains in place.

There is continued enlargement of the cardiac silhouette
persists with only
minimal fullness of pulmonary vessels. Bibasilar atelectasis
persists. There
is blunting of the left costophrenic angle that could represent
pleural fluid
or superimposition of soft tissues.
.
LENI [**1-19**]
.
IMPRESSION: Negative for DVT bilaterally.
.
CXR [**1-21**] -
The NG tube was removed in the meantime interval. The
cardiomediastinal
silhouette is unchanged including moderate-to-severe
cardiomegaly. There is
overall interval improvement of the pulmonary edema which is
almost completely
resolved. No substantial pleural effusion is demonstrated.
Minimal bibasilar
atelectasis is seen.
.
Cardiac Catheterization [**1-22**]:
1.  Selective coronary angiography of this right dominant system

revealed single vessel coronary artery disease.  The LMCA had
minimal
disease.  The LAD had a mid vessel high grade 90% lesion with
thrombus.
The LCX and RCA had patent prior stents without angiographically

apparent obstructive lesions.
2.  Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 20 mm Hg and LVEDP of 30 mm Hg.  There
was
moderate pulmonary arterial hypertension of 57/25 mm Hg.  There
was a
normal systemic arterial blood pressure of 110/59 mm Hg.  There
was no
gradient upon pullback of the catheter from LV to the aorta.
The
cardiac index was mildly low at 2.0 l/min/m2.
3. Left ventriculography was deferred due to renal dysfunction.
4. Stenting of LAD stent thrombosis lesion with a Xience 3x18mm
stent

FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Moderate biventricular diastolic dysfunction.
3. Moderate pulmonary arterial hypertension.
4. Stenting of LAD with drug eluting stent.
.
CXR [**1-22**] - mild pulmonary edema.
.


Brief Hospital Course:
Patient is a 68 y/o male w/ a hx of CAD and MI who is transfered
from NEBH after a STEMI following spinal surgery complicated by
atrial fibrillation and resolving acute renal failure.

# Hypoxia.  Patient was admitted w/ 95% oxygen saturation on
non-rebreather mask.  He was afebrile and tachypneic.  This was
felt to be primarily [**3-15**] pulmonary vascular congestion [**3-15**]
Anterior MI and poor EF, confirmed by exam, CXR showing vascular
engorgement and BNP of [**Numeric Identifier **] on admission.  DDx included PNA,
PE, atelectasis and hypoventilation given abdominal distension
(see below) among others.  Pt. was diuresed with lasix gtt w/
volume balance of nearly -5L w/o significant improvement in
oxygenation.  On HD#2, patient became febrile to 102F Rectal and
given the continued oxygen requirement w/ leukocytosis (20.4K)
and fever, patient was started on broad spectrum antibiotic
therapy w/ IV Vancomycin/Zosyn.  On HD#3 Levofloxacin was added
for atypical coverage given no improvement in oxygenation.  CT
chest on [**1-20**] showed mild pulmonary edema w/calcified plaques.
LENIs b/l were negative.  BCx, urinary legionella and Influenza
nasal washings were negative.  As patient's prolonged ileus
resolved, he became more mobile and he continued to diurese, his
O2 requirement improved to 2L NC w/ saturations in 92-95% range
by [**2195-1-22**] and was weaned off lasix gtt.  His Vancomycin and
Zosyn were discontinued.  On [**1-22**], patient underwent caridiac
catheterization, received 3L of IVF and returned to afib w/ RVR
(see below) w/ resultant flash pulmonary edema.  Pt. was
diuresed further w/ IV lasix with additional 1L negative and
resolution of oxygen requirement.  On day of discharge, patient
had clear lungs except for a few crackles at the bases and only
trace peripheral edema and oxygen saturation of 94-96% on RA.
He was afebrile w/ persistent Leukocytosis of 16.2K (Reported
baseine of WBC of up yo 14K).  His smear was negative for
atypical cells and differential was slightly neutrophil
predominant.  Patient completed 10 days of Levofloxacin renally
dosed for suspected HCAP.

# CORONARIES: The patient has a history of CAD, with prior MI,
and multiple PCIs, with 2 stents placed in [**2192**]. The patient
with chest pain following surgery, with prominant aterior ST
elevations c/w mid LAD. The patinet was treated conservatively,
and was not anticoagulated due to risk of bleeding in the
post-operative period. The patient's troponin's peaked at 72at
OSH and CK maximum 551 at [**Hospital1 18**]. He remained chest pain free
after his intial event.  The patient was begun on heparin gtt
after developing new AF peri-MI.  He was continued on ASA 81 mg
daily, metoprolol 100mg TID (discontinued [**3-15**] hypotension on
[**1-17**]) and Simvastatin.  Patient denied CP throughout
hospitalization but reported SOB at rest until HD#3.  Pt. was
restarted on Metoprolol on [**1-21**], but stopped given issues with
bradycardia detailed below.  He underwent cardiac
catheterization on [**1-22**] showing single vessel disease in LAD,
90% w/ thrombosis and received DES.  Ventriculography was
deferred [**3-15**] elevated Cr (see below).  He was discharged on ASA
325, Plavix 75mg, Acebutolol 400 mg [**Hospital1 **], Simvastatin 80mg, and
2.5 mg lisinopril QD.  He was free of CP and SOB at time of
discharge.

# RHYTHM: Patient developed AF in post-MI setting, with HR of
140s, managed on amioderone, dilt gtt, and metoprolol at NEBH.
Pt. had a transvenous pacer in place for a reported pause at
OSH, this was removed on HD2 and no evidence of pauses was noted
on telemetry.  On arrival pt was in AF w/ RVR, and started on
heparin gtt, loaded w/ IV amiodarone followed by amiodarone gtt
and diltiazem gtt for rate control.  Metoprolol resulted in
singificant hypotension, SBPs 80s mmHg.  A 200 J cardioversion
was attempted on HD#2 w/ patient converting to sinus for
30seconds and eventual reversion to atrial fibrillation.
Amiodarone was discontinued, cardizem gtt was continued.
Patient had failed two transitions to PO diltiazem of 60mg QID
with recurrence of RVR.  Pt. was also intremittently in atrial
flutter.  He was started on Metoprolol titrated to 25mg TID by
[**1-24**].  He was eventually weaned off diltiazem gtt after
catheterization at a dose of 90mg QID on [**1-23**].  He was
continued on heparing gtt since HD#1 and transitioned to
warfarin.  Pt. converted to sinus rhythm on [**1-24**], but reverted
by [**1-26**].  Heparin was discontinued once INR reached > 2 over 24
hours and patient continued on warfarin of 4 mg QD.  On [**1-27**]
patient was noted to have an asymptomatic pause of 5 seconds on
telemetry w/o conversion from atrial fibrillation.  He was seen
by Electrophysiology who recommended stopping his diltiazem and
metoprolol and starting acebutolol 400 mg [**Hospital1 **].  He will follow
up with Dr. [**Last Name (STitle) **] and have a Holter in 1 month as an outpatient.
He is being discharged with VNA whow will fax his INR results to
his PCP.

# PUMP: Echo at NEBH showed EF of 40% with apical and septal HK,
ECHO at [**Hospital1 18**] showed mild symmetric left ventricular hypertrophy
with regional systolic dysfunction c/w CAD (mid-LAD
distribution)and mild MR w/ EF of 35-40%.  Initially was in
failure on exam (crackles on exam posteriorly to apices) and JVP
to mandible.  He was aggressively diuresed w/ lasix gtt,
intermitent use of thiazide for total of x L negative over LOS.
Given stable BPs, metoprolol was restarted on [**1-22**] (however
this was changed to acebutolol prior to discharge as above.  On
[**1-23**] patient was transitioned to IV lasix and then 120 mg PO
daily.  On exam had no pulmonary edema and trace edema at legs
b/l.

# Leukocytosis: Marked leukocytosis following surgery, was felt
to be likely stress response and possible bowel distension [**3-15**]
prolonged post-opeartive ileus. Pt. defevesced by [**1-19**].  Please
see Hypoxia for infectious w/up.  Patient did have fever up to
102F rectally.  UCx, C.Diff and BCx were negative at time of
discharge.  WBC peaked at 20.4K.  No source of infection could
be identified and he was afebrile w/ persistent Leukocytosis of
16.2 K (Reported baseine of WBC of up yo 14K).  His smear was
negative for atypical cells and differential was slightly
neutrophil predominant.

# Anemia: Pronounced Hct drop in days following surgery to HCT
of 30.  This has remained stable throughtout admission and was
suspect may be [**3-15**] to IVF prior to surgery.  No sources of
bleeding were noted, including benign back exam, w/o
neurological deficits.  Pt. did not recall history of
colonoscopy or endoscopy.  At time of discharge HCT was 27.4.

# Prolonged post operateive ileus.  Pt. w/ distended abdomen and
no BM x2 days on admission.  Pt. was started on senna, colace,
bisacodyl.  Presentation was consistent w/ post operative ileus,
KUB consistent w/ this and no stool in vault.  Pt. was kept NPO
and received NGT w/ > 1L output at time of placement.  By HD2,
patient had small BMs and NGT declined, abdominal distension
decreased.  Patient was advanced to clears, then regular cardiac
healthy diet with good tolerance and BMs Q3d.

# Spinal surgery. Pt underwent a lumbar spine surgery ([**2195-1-14**])
for spinal stenosis/L3-L5 right laminectomy, posteior fusion,
foraminotomy and repair of dural tear (by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] at NEBH).
He was noted w/ stabilization device spaning the lower lumbar
and lumbosacral levels of the spine on KUB.  Given leukocytosis
there was some concern regarding infection, but no signs of
infection were noted on exam.  Ortho-spine service was consulted
who agreed w/ assessment and advised activity.  Pain was treated
with Tylenol RTC and IV morphine PRN, which was changed to
oxycodone 5mg q4h prn at time of discharge.  Pain at time of
discharge was [**3-23**] and patient was able to ambulate w/ walker.

FEN: cardiac/low sodium diet
PROPHYLAXIS:
-DVT ppx with systemic heparin
-Pain managment with IV morphine
-Bowel regimen as listed above
CODE: Full, discussed with family and patient.

Patient was discharged home in a hemodynamically stable
condition, w/o chest pain or dyspnea.

Medications on Admission:
Home Medications-
Simvastatin 40mg dialy
Folic acid 1mg daily
Metoprolol 100mg qam and 50mg qpm
Niaspan 500mg daily
aspirin 81mg daily

Medications at Time of Transfer:
Zocor 40mg daily
heparin gtt
amioderone 400mg [**Hospital1 **]
Cardizem gtt
Lopressor 5-10mg q6h
Asa 81
Altace 2.5mg daily
morphine 2-4mg IV q2h
Tylenol 650mg q6h
morphine PCA
Lopressor 100mg [**Hospital1 **]
Reglan
Folic acid
Thiamine


Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for back pain.
Disp:*20 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
5. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
Check CBC, INR, PT, and panel 7(electrolytes, Cr, BUN).  Please
fax the results to Dr. [**Last Name (STitle) 4829**] at 617-[**Medical Record Number 102022**].
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*60 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Acebutolol 200 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Primary Diagnoses:
1. ST-Elevation Myocardial Infarcion
2. Atrial Fibrillation
3. Acute Systolic Heart Failure
4. Bowel Ileus
5. Acute Renal Failure
6. Spinal Stenosis s/p surgery

Secondary Diagnoses:
7. Coronary Artery Disease
8. Hypertension
9. Hypercholesterolemia


Discharge Condition:
afebrile, hemodynamically stable


Discharge Instructions:
You were admitted to the hospital with a heart attack after your
back surgery.  You had symptoms of congestive heart failure and
were given Lasix (furosemide) to remove fluid from your lungs to
help you breathe better.  Your heart was in an abnormal rhythm
called atrial fibrillation.  You were started on medictions to
control your heart rate and to thin your blood.  You had a
cardiac catheterization which showed a partial blockage in one
of the arteries that supplies the heart.  A stent was put in to
relieve this blockage.  You improved and you were discharged
home.

The following changes were made to your medications:
Start taking aspirin 81mg by mouth once a day.
Start taking Plavix 75mg by mouth once a day.
Start taking Acebutolol 500mg twice a day
Start taking Coumadin 4mg by mouth once a day.

You should never stop taking your Plavix or aspirin unless
instructed by your cardiologist.  You should continue to take
Coumadin as instructed to thin your blood.  If you develop any
bleeding or notice blood in your bowel movements, you should
come to the emergency room immediately.

You will need a holter monitor in one month to evaluate if you
are still in atrial fibrillation.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500ml

You should follow-up with your PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.  You should see
your cardiologist within 1-2 weeks.

You should call your doctor or come to the emergency room for
any fevers > 100.4, chills, night sweats, chest pain, shortness
of breath, heart palpitations, abdominal pain, blood in your
bowel movements, leg swelling or any other symptoms that concern
you.

Followup Instructions:
Please see your PCP [**Last Name (NamePattern4) **] [**2-12**] weeks.

An appointment has been made for you to follow up with your
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], you have an appointment scheduled
for [**2-17**] at 11:45 at the [**Hospital6 **] office on
[**Doctor Last Name 102023**], [**Location (un) 86**].  The office number is [**Telephone/Fax (1) 7960**].  Dr.
[**Last Name (STitle) **] requests that you follow up at least once for evaluation
after discharge.

You should have your blood drawn to check your INR in 2 days and
fax this result to your primary doctor, Dr. [**Last Name (STitle) 4829**], at
[**Telephone/Fax (1) 102024**].



Completed by:[**2195-1-28**]
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute systolic heart failure,Paralytic ileus,Acute kidney failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Leukocytosis, unspecified,Hypoxemia,Pure hypercholesterolemia,Long-term (current) use of anticoagulants'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: The patient is 68 y/o M w/hx of CAD s/p MI in [**2186**], HTN,
hyperlipidemia who is transferred from [**Hospital3 **] for STEMI. Pt
was first admitted on [**2195-1-14**] and underwent L3-L5 laminectomy,
fusion, foraminotmy, and durotomy with bone autograft.
Posteroperatively, the patient developed chest pain, which was
treated with IV NTGL, morphine, and metoprolol. The patient was
treated with these conservative measures, and given resolution
of chest pain and contraindication of anticoagulation, cardiac
catheterization was deffered. Cardiac markers were cycled, and
CK peaked on [**2195-1-15**] at 5021, trop 70, and has trended down
since. He has remained chest pain free since.
On [**2195-1-16**], the patient went into atrial fibrillation with a
rapid ventricular response of 144, and the patient was
transfered to the NEBH CCU. IV lopressor was administered,
without effect. The patient was started on a diltiazem gtt, with
improvement of HR control to 90s-120s. The patient remained
asymptomatic and hemodynamically stable throughout. He was
managed with a dilt gtt, PO lopressor and amioderone. At that
time, heparin gtt was also started. The patient converted to
sinus rhythm, and the dilt gtt was stopped. On the morning of
transfer, the patient went back into afib again with HRs in the
140 and Dilt gtt was restarted. Lopressor increased to 200mg PO
BID and amio to 400mg PO BID. Pt was reportedly noted to have
long pauses and ? of new LBBB, and had transvenous pacer wire
placed on [**2195-1-16**].
On the night prior to transfer, the patient spiked temp to
101.6, despite RTC tylenol. CXR was obtained and UA and culture
was taken. Despite a normal WBC on admission, the patient has
had a leukocytosis since [**1-14**] of 26.5. He has not received
antibiotics and no blood cultures were drawn.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**5-/2186**]: mid LCx with BMS
[**3-/2192**]: PCI to RCA and LAD, likely DES following + ETT
-PACING/ICD: transvenous pacer placed [**2195-1-16**] at NEBH
3. OTHER PAST MEDICAL HISTORY:
.
s/p spine surgery w/ laminectomy, fusion, and instrumentation

MEDICATION ON ADMISSION: Home Medications-
Simvastatin 40mg dialy
Folic acid 1mg daily
Metoprolol 100mg qam and 50mg qpm
Niaspan 500mg daily
aspirin 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T=98.7 BP= 95/51 HR= 78 RR= 25 O2 sat= 93% on 50% O2
GENERAL: WDWN male, tachypnic and diaphoretic. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Quit smoking:
-ETOH: 2 glasses of wine daily.
-Illicit drugs: No history of illicit drugs
.
The patient is married with four children He is a retired
construction worker. 

### Response:
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute systolic heart failure,Paralytic ileus,Acute kidney failure, unspecified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Leukocytosis, unspecified,Hypoxemia,Pure hypercholesterolemia,Long-term (current) use of anticoagulants'}
