CHIEF COMPLAINT: elective left iliac stenting

PRESENT ILLNESS: Mr. [**Known lastname **] is a 54 year old gentleman with hx of CAD, PVD, CRI,
HTN, HLD, bilateral subclavian stenosis, renal stenosis and
multiple stents with bilateral LE pain with activity who
presented for elective stenting of Left Common Iliac Artery.  He
had left CIA stenosis with gradient of 30mmHg which was
successfully stented in the Cath lab.  He did receive heparin in
the cath lab. When groin sheaths were being pulled, patient had
significant drop in BP to 60s systolic, thought to be vasovagal;
patient required IV fluids, IV atropine X 2, IV zofran, IV
benadryl. He was temporarily started on dopamine and
phenylephrine, transfused emergently with 4 units of pRBCs for
concern of retroperitoneal bleed. CT confirmed RP bleed, so
patient was taken back to cath lab for placement of covered
stent in CIA to help prevent further bleeding and tamponade RP
bleed.  Vascular Surgery was notified, and patient was
transferred to CCU for monitoring.
.
Patient's bilateral lower extremity pain and numbness, left
greater than right, began in the late spring, relieved by rest.
He is able to walk 2 to 5 miles before symptoms began, per OMR
notes. Patient's local cardiologist had prescribed 80mg
Prednisone to be taken the day prior to procedure, per notes.
.
On arrival to the floor, patient denied chest pain, shortness of
breath, nausea, light headedness, orthopnea. He did admit to an
episode of mild chest pain when blood pressures were low.  He
denied having lost consciousness during the episode.  His ECG
was noted to have ST elevations in V1-V3 (inferior leads with
lots of artifact); ECG on arrival to the CCU showed resolution
of changes and normalization of ECG.
.
On review of systems, he denies any cough, hemoptysis, black
stools or red stools (last BM yesterday). Denies fevers, chills
or rigors. Urine draining in Foley.  No CP or palpiations.  No
SOB.  + right flank pain.  + RLQ abdominal pain, hurts when
moving.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:  [**2156-4-1**]: 99% innominate
stenosis, s/p stenting
- [**2158-12-20**] Left heart Catheterization and Coronary Angiography:
Residual single vessel non obstructive coronary artery
disease. Normal LMCA. 50% distal LAD stenosis. Patent LCX w mild
diffuse disease.  Patent proximal RCA stent and 30% distal
stenosis.
  - Limited resting hemodynamics: LVEDP of 22mmHg. moderate
systemic arterial hypertension with a central aortic pressure of
165/88 mmHg. No significant gradient across aortic valve.
  - Nonselective angiography of renal arteries: 2 patent stents
in the left lower and middle renal arteries.  The right renal
artery was known occluded.  bilateral internal iliac arteries
were noted to be occluded.
- [**2158-6-23**] cardiac catheterization: LAD with a 50% distal lesion.
Cx with mild diffuse disease, RCA with a 70-80% eccentric
stenosis in the proximal vessel, s/p Cypher stenting.
   - Angiography of right renal artery revealed a total
occlusion. Left renal artery with patent stents with a 40%
restenosis. LE angio revealing bilateral internal iliac artery
occlusion. Right iliac artery stent patent.
3. OTHER PAST MEDICAL HISTORY:
- Former tobacco abuse, quit [**2155**]
- PVD
- Bilateral renal artery stenosis with an occluded right renal
artery, atrophic right kidney/iliac artery disease
- [**2156-4-2**]: DES to left lower renal artery, Bare metal stenting of
left middle renal artery, successful stenting of right common
iliac artery
- Bilateral subclavian stenosis. [**2156-12-27**]: s/p bilateral stenting
- [**2159-7-23**]: Bilateral Carotid Ultrasound:  Mild 1-39% bilateral
internal carotid artery stenosis without appreciable change from
prior carotid ultrasound
- [**2159-7-23**]: Bilateral Ankle/Arm Indices:  Ankle brachial index
data
continued to suggest normal arterial flow within both lower
extremities at rest without evidence of claudication criteria.
- [**2158-6-30**]:  90% ISR of right subclavian artery s/p angioplasty
and stenting
- Lower GIB due to an ulcer at age 18, none since
- CRI
- Claustrophobia
- Anxiety
- GERD
- Degenerative disc disease/back pain

MEDICATION ON ADMISSION: Oxycodone-Acetaminophen [**12-2**] TAB PO Q4H:PRN pain
    Acetaminophen 650 mg PO Q4H:PRN fever, pain
    Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN
    Simethicone 40-80 mg PO QID:PRN abdominal discomfort
    Aspirin 325 mg PO DAILY
    Amlodipine 5 mg PO/NG [**Hospital1 **]
    CloniDINE 0.1 mg PO BID
    Clopidogrel 75 mg PO/NG DAILY Start: In am
    Diltiazem Extended-Release 240 mg PO DAILY Start: In am
    Venlafaxine XR 75 mg PO DAILY Start: In am
    Pantoprazole 40 mg PO Q24H Start: In am
    Pravastatin 80 mg PO DAILY
    Ezetimibe 10 mg PO DAILY
    Valsartan 320 mg PO/NG DAILY
    Multivitamins 1 TAB PO/NG DAILY

ALLERGIES: Iodine; Iodine Containing / Flomax / Shellfish Derived

PHYSICAL EXAM: GENERAL: WNWD gentleman, lying still supine, in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. mmm
NECK: Supple with flat JVP.
CARDIAC:  RR, normal S1, S2. + systolic murmur @ LLSB no
radiation
LUNGS: No chest wall deformities. Respirations unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, extremely tender in right lower quadrant and
inguinal area, mild tenderness in right mid quadrant.
BACK: no ecchymosis of lower back, some mild tenderness of right
lower back
EXTREMITIES: No c/c/e. 2+ DP and PT pulses bilaterally.

FAMILY HISTORY: Father with hypertension.  DM2 in family. No known heart
attacks.

SOCIAL HISTORY: Per OMR notes, patient is married with three children.  He owns
a bread franchise.  His daughter [**Name (NI) 402**] [**Name (NI) **]
([**Telephone/Fax (1) 73318**]accompanied him to the procedure.
Tobacco: Patient had smoked 2ppd x 33 years. He quit in [**2155**]
ETOH: Socially;
Wife: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 73319**]
Atherosclerosis of native arteries of the extremities with intermittent claudication,Accidental puncture or laceration during a procedure, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Degeneration of lumbar or lumbosacral intervertebral disc,Esophageal reflux,Anxiety state, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of peptic ulcer disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Ath ext ntv at w claudct,Accidental op laceration,Ocl crtd art wo infrct,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,Lumb/lumbosac disc degen,Esophageal reflux,Anxiety state NOS,Status-post ptca,Prsnl hst peptic ulcr ds,Abn react-procedure NEC
Name:  [**Known lastname 12097**],[**Known firstname **]                   Unit No:   [**Numeric Identifier 12098**]

Admission Date:  [**2159-8-10**]              Discharge Date:   [**2159-8-13**]

Date of Birth:  [**2104-12-4**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine; Iodine Containing / Flomax / Shellfish Derived

Attending:[**First Name3 (LF) 1281**]
Addendum:
Final Report
ARTERIAL DOPPLER LOWER EXTREMITY

REASON: Duplex upper extremity bilateral.

FINDINGS: Duplex evaluation was performed of both subclavian and
brachial arteries. Waveforms and velocities are normal
throughout with triphasic tracings.

IMPRESSION:
No evidence of a subclavian or brachial artery stenosis in
either upper extremity.


Discharge Disposition:
Home

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1282**] MD [**MD Number(2) 1283**]

Completed by:[**2159-8-16**]

Admission Date:  [**2159-8-10**]              Discharge Date:   [**2159-8-13**]

Date of Birth:  [**2104-12-4**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine; Iodine Containing / Flomax / Shellfish Derived

Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
elective left iliac stenting

Major Surgical or Invasive Procedure:
peripheral angiogram
left common iliac artery stenting
iliac catheterization for active extravasation (retroperitoneal
bleeding) treated with Viabahn stent graft

History of Present Illness:
Mr. [**Known lastname **] is a 54 year old gentleman with hx of CAD, PVD, CRI,
HTN, HLD, bilateral subclavian stenosis, renal stenosis and
multiple stents with bilateral LE pain with activity who
presented for elective stenting of Left Common Iliac Artery.  He
had left CIA stenosis with gradient of 30mmHg which was
successfully stented in the Cath lab.  He did receive heparin in
the cath lab. When groin sheaths were being pulled, patient had
significant drop in BP to 60s systolic, thought to be vasovagal;
patient required IV fluids, IV atropine X 2, IV zofran, IV
benadryl. He was temporarily started on dopamine and
phenylephrine, transfused emergently with 4 units of pRBCs for
concern of retroperitoneal bleed. CT confirmed RP bleed, so
patient was taken back to cath lab for placement of covered
stent in CIA to help prevent further bleeding and tamponade RP
bleed.  Vascular Surgery was notified, and patient was
transferred to CCU for monitoring.
.
Patient's bilateral lower extremity pain and numbness, left
greater than right, began in the late spring, relieved by rest.
He is able to walk 2 to 5 miles before symptoms began, per OMR
notes. Patient's local cardiologist had prescribed 80mg
Prednisone to be taken the day prior to procedure, per notes.
.
On arrival to the floor, patient denied chest pain, shortness of
breath, nausea, light headedness, orthopnea. He did admit to an
episode of mild chest pain when blood pressures were low.  He
denied having lost consciousness during the episode.  His ECG
was noted to have ST elevations in V1-V3 (inferior leads with
lots of artifact); ECG on arrival to the CCU showed resolution
of changes and normalization of ECG.
.
On review of systems, he denies any cough, hemoptysis, black
stools or red stools (last BM yesterday). Denies fevers, chills
or rigors. Urine draining in Foley.  No CP or palpiations.  No
SOB.  + right flank pain.  + RLQ abdominal pain, hurts when
moving.

Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:  [**2156-4-1**]: 99% innominate
stenosis, s/p stenting
- [**2158-12-20**] Left heart Catheterization and Coronary Angiography:
Residual single vessel non obstructive coronary artery
disease. Normal LMCA. 50% distal LAD stenosis. Patent LCX w mild
diffuse disease.  Patent proximal RCA stent and 30% distal
stenosis.
  - Limited resting hemodynamics: LVEDP of 22mmHg. moderate
systemic arterial hypertension with a central aortic pressure of
165/88 mmHg. No significant gradient across aortic valve.
  - Nonselective angiography of renal arteries: 2 patent stents
in the left lower and middle renal arteries.  The right renal
artery was known occluded.  bilateral internal iliac arteries
were noted to be occluded.
- [**2158-6-23**] cardiac catheterization: LAD with a 50% distal lesion.
Cx with mild diffuse disease, RCA with a 70-80% eccentric
stenosis in the proximal vessel, s/p Cypher stenting.
   - Angiography of right renal artery revealed a total
occlusion. Left renal artery with patent stents with a 40%
restenosis. LE angio revealing bilateral internal iliac artery
occlusion. Right iliac artery stent patent.
3. OTHER PAST MEDICAL HISTORY:
- Former tobacco abuse, quit [**2155**]
- PVD
- Bilateral renal artery stenosis with an occluded right renal
artery, atrophic right kidney/iliac artery disease
- [**2156-4-2**]: DES to left lower renal artery, Bare metal stenting of
left middle renal artery, successful stenting of right common
iliac artery
- Bilateral subclavian stenosis. [**2156-12-27**]: s/p bilateral stenting
- [**2159-7-23**]: Bilateral Carotid Ultrasound:  Mild 1-39% bilateral
internal carotid artery stenosis without appreciable change from
prior carotid ultrasound
- [**2159-7-23**]: Bilateral Ankle/Arm Indices:  Ankle brachial index
data
continued to suggest normal arterial flow within both lower
extremities at rest without evidence of claudication criteria.
- [**2158-6-30**]:  90% ISR of right subclavian artery s/p angioplasty
and stenting
- Lower GIB due to an ulcer at age 18, none since
- CRI
- Claustrophobia
- Anxiety
- GERD
- Degenerative disc disease/back pain

Social History:
Per OMR notes, patient is married with three children.  He owns
a bread franchise.  His daughter [**Name (NI) 402**] [**Name (NI) **]
([**Telephone/Fax (1) 73318**]accompanied him to the procedure.
Tobacco: Patient had smoked 2ppd x 33 years. He quit in [**2155**]
ETOH: Socially;
Wife: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 73319**]

Family History:
Father with hypertension.  DM2 in family. No known heart
attacks.

Physical Exam:
GENERAL: WNWD gentleman, lying still supine, in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. mmm
NECK: Supple with flat JVP.
CARDIAC:  RR, normal S1, S2. + systolic murmur @ LLSB no
radiation
LUNGS: No chest wall deformities. Respirations unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, extremely tender in right lower quadrant and
inguinal area, mild tenderness in right mid quadrant.
BACK: no ecchymosis of lower back, some mild tenderness of right
lower back
EXTREMITIES: No c/c/e. 2+ DP and PT pulses bilaterally.

Pertinent Results:
LABS upon ADMISSION:

[**2159-8-10**] 05:55PM BLOOD WBC-14.3* RBC-3.87* Hgb-12.4* Hct-35.0*
MCV-90 MCH-32.1* MCHC-35.5* RDW-13.6 Plt Ct-241
[**2159-8-10**] 08:00PM BLOOD Neuts-94.0* Lymphs-4.6* Monos-1.1*
Eos-0.1 Baso-0.2
[**2159-8-10**] 10:18PM BLOOD UreaN-29* Creat-1.4* Na-143 K-5.1 Cl-113*
[**2159-8-11**] 03:56AM BLOOD Glucose-141* UreaN-32* Creat-1.5* Na-142
K-4.9 Cl-109* HCO3-21* AnGap-17
[**2159-8-10**] 10:18PM BLOOD CK(CPK)-57
[**2159-8-11**] 03:56AM BLOOD CK(CPK)-45*
[**2159-8-10**] 10:18PM BLOOD CK-MB-3 cTropnT-0.02*
[**2159-8-11**] 03:56AM BLOOD CK-MB-2 cTropnT-<0.01
[**2159-8-11**] 03:56AM BLOOD Calcium-8.8 Phos-5.9*# Mg-2.2

LABS upon DISCHARGE:

[**2159-8-13**] 05:50AM BLOOD WBC-8.6 RBC-3.69* Hgb-11.3* Hct-32.7*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.9 Plt Ct-155
[**2159-8-13**] 05:50AM BLOOD Glucose-104* UreaN-26* Creat-1.3* Na-139
K-3.9 Cl-106 HCO3-24 AnGap-13
[**2159-8-13**] 05:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.3

REPORTS:

Iliac cath: [**2159-8-10**]: Patent right iliac, left iliac with 60-70%
mid iliac with gradient was stented 0% residual, patent SFA,
[**Doctor Last Name **], TPT, occluded AT

CT abd/pelvis [**2159-8-10**]:
1. Large right-sided retroperitoneal hematoma extending from the
level of theright external iliac artery superiorly to the level
of the right kidney,
extending inferiorly to the right inguinal canal with mass
effect on the
bladder.
2. Multiple low-density lesions within the liver and a single
low-density
lesion within the spleen, too small to characterize but possibly
representing benign cysts or hemangiomas.
3. Multiple prominent retroperitoneal lymph nodes, not enlarged
by size
criterion, possibly reactive in nature.
4. Colonic diverticulosis.

ECG: [**2159-8-10**]: Sinus rhythm rate 63. Intervals normal. No ST/T
changes.


Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 54 year old male with diffuse peripheral
artery disease, coronary artery disease who presented for
elective peripheral angiogram and left common iliac artery
stenting due to exertional claudication.  His catheterization
was complicated by a retroperitoneal bleed, which was stabilized
after repeat catheterization with a covered stent.  He was
transferred to the CCU where his retroperitoneal bleed and pain
were monitored.  CT scan of the abdomen and pelvis showed a
large right-sided retroperitoneal hematoma extending from the
level of the right external iliac artery superiorly to the level
of the right kidney, extending inferiorly to the right inguinal
canal with mass effect on the bladder.  The patient's right
flank and RLQ abdominal pain was treated with
Oxycodone/Acetaminophen and his pain gradually improved during
his admission.  He did not show any signs of superimposed
infection.  He was seen by our vascular team and the patient was
discharged with expectation that the retroperitoneal blood would
resorb spontaneously over time.
.
The patient's peripheral arterial disease was treated with
continuation of his aspirin and plavix.  He received a bilateral
upper extremity ultrasound to evaluate stenosis of his
subclavian and brachial veins in order to assess candidacy for
future stenting of these vessels.  The final report of the
ultrasound is not available at the time of this discharge
summary, but should be followed up by his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 73320**].
.
The patient's hypertensive medications were initially held in
the setting of his retroperitoneal bleed, but were shortly
restarted as his hypertension persisted.  He did complain of
fatigue after taking all of his antihypertensives at once,
therefore we staggered administration of his medications and
recommended he continue this upon discharge.
.
The patient's chronic back pain was managed with
oxycodone/acetaminophen as needed according to his home dosing.
.
The patient was full code during this admission.


Medications on Admission:
 Oxycodone-Acetaminophen [**12-2**] TAB PO Q4H:PRN pain
    Acetaminophen 650 mg PO Q4H:PRN fever, pain
    Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN
    Simethicone 40-80 mg PO QID:PRN abdominal discomfort
    Aspirin 325 mg PO DAILY
    Amlodipine 5 mg PO/NG [**Hospital1 **]
    CloniDINE 0.1 mg PO BID
    Clopidogrel 75 mg PO/NG DAILY Start: In am
    Diltiazem Extended-Release 240 mg PO DAILY Start: In am
    Venlafaxine XR 75 mg PO DAILY Start: In am
    Pantoprazole 40 mg PO Q24H Start: In am
    Pravastatin 80 mg PO DAILY
    Ezetimibe 10 mg PO DAILY
    Valsartan 320 mg PO/NG DAILY
    Multivitamins 1 TAB PO/NG DAILY

Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Venlafaxine 75 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO Q
Saturday/Sunday/Tuesday/Thursday.
7. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes X 2 as needed for chest pain.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Valsartan 320 mg Tablet Sig: One (1) Tablet PO Q Evening.
12. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Retroperitoneal Bleed
Peripheral Arterial Disease
Coronary Artery Disease
Hypertension
Dyslipidemia


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


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

You had a peripheral angiogram for the complaint of pain when
you walk.  You received a stent to your left mid iliac artery.
The procedure was done through your right groin and was
complicated by a large bleed into your right retroperitoneal
space, which is the space that surrounds your right kidney.  You
were seen by the vascular surgeons who feel that you do not need
surgery to evacuate the blood from that space; your body should
resorb the blood on its own.

It is very important that that you follow up with your
cardiologist who can monitor your progress.  Please let her know
if you start to develop worsening pain or if you begin to have
fevers.

You will need to continue to take your ASA and Plavix as
prescribed.

There is some question as to whether taking a medication like
Nexium can interfere with the function of Plavix.  As you know,
Plavix is very important to keep your stents open.  We
understand that you've had some difficulty controlling your
reflux symptoms with other medications, aside from Nexium, and
that you have been on this combination of medications for a long
time.  Please remember to discuss this issue with your
cardiologist.

Please remember to stagger your blood pressure medications, as
previously discussed, so that you are not taking them all at
once -- this should help keep your blood pressure from dropping
suddenly and causing you fatigue.

You may continue to take percocet for your pain, as you have
been using at home for your chronic back pain.  Please remember
that percocet has tylenol in it, so you should not take more
than 4grams of tylenol per day in total.
Please do not operate any heavy machinery after taking this
medication.
You may use Docusate (Colace) stool softeners while taking this
medication.

Activity and wound per discharge instructions.


Followup Instructions:
Please be sure to keep your followup appointments as below.

Dr. [**Last Name (STitle) 11250**] - [**2159-8-17**] @ 8:00 AM



Completed by:[**2159-8-14**]
{'Atherosclerosis of native arteries of the extremities with intermittent claudication,Accidental puncture or laceration during a procedure, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Degeneration of lumbar or lumbosacral intervertebral disc,Esophageal reflux,Anxiety state, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of peptic ulcer disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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



### Clinical text :
CHIEF COMPLAINT: elective left iliac stenting

PRESENT ILLNESS: Mr. [**Known lastname **] is a 54 year old gentleman with hx of CAD, PVD, CRI,
HTN, HLD, bilateral subclavian stenosis, renal stenosis and
multiple stents with bilateral LE pain with activity who
presented for elective stenting of Left Common Iliac Artery.  He
had left CIA stenosis with gradient of 30mmHg which was
successfully stented in the Cath lab.  He did receive heparin in
the cath lab. When groin sheaths were being pulled, patient had
significant drop in BP to 60s systolic, thought to be vasovagal;
patient required IV fluids, IV atropine X 2, IV zofran, IV
benadryl. He was temporarily started on dopamine and
phenylephrine, transfused emergently with 4 units of pRBCs for
concern of retroperitoneal bleed. CT confirmed RP bleed, so
patient was taken back to cath lab for placement of covered
stent in CIA to help prevent further bleeding and tamponade RP
bleed.  Vascular Surgery was notified, and patient was
transferred to CCU for monitoring.
.
Patient's bilateral lower extremity pain and numbness, left
greater than right, began in the late spring, relieved by rest.
He is able to walk 2 to 5 miles before symptoms began, per OMR
notes. Patient's local cardiologist had prescribed 80mg
Prednisone to be taken the day prior to procedure, per notes.
.
On arrival to the floor, patient denied chest pain, shortness of
breath, nausea, light headedness, orthopnea. He did admit to an
episode of mild chest pain when blood pressures were low.  He
denied having lost consciousness during the episode.  His ECG
was noted to have ST elevations in V1-V3 (inferior leads with
lots of artifact); ECG on arrival to the CCU showed resolution
of changes and normalization of ECG.
.
On review of systems, he denies any cough, hemoptysis, black
stools or red stools (last BM yesterday). Denies fevers, chills
or rigors. Urine draining in Foley.  No CP or palpiations.  No
SOB.  + right flank pain.  + RLQ abdominal pain, hurts when
moving.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:  [**2156-4-1**]: 99% innominate
stenosis, s/p stenting
- [**2158-12-20**] Left heart Catheterization and Coronary Angiography:
Residual single vessel non obstructive coronary artery
disease. Normal LMCA. 50% distal LAD stenosis. Patent LCX w mild
diffuse disease.  Patent proximal RCA stent and 30% distal
stenosis.
  - Limited resting hemodynamics: LVEDP of 22mmHg. moderate
systemic arterial hypertension with a central aortic pressure of
165/88 mmHg. No significant gradient across aortic valve.
  - Nonselective angiography of renal arteries: 2 patent stents
in the left lower and middle renal arteries.  The right renal
artery was known occluded.  bilateral internal iliac arteries
were noted to be occluded.
- [**2158-6-23**] cardiac catheterization: LAD with a 50% distal lesion.
Cx with mild diffuse disease, RCA with a 70-80% eccentric
stenosis in the proximal vessel, s/p Cypher stenting.
   - Angiography of right renal artery revealed a total
occlusion. Left renal artery with patent stents with a 40%
restenosis. LE angio revealing bilateral internal iliac artery
occlusion. Right iliac artery stent patent.
3. OTHER PAST MEDICAL HISTORY:
- Former tobacco abuse, quit [**2155**]
- PVD
- Bilateral renal artery stenosis with an occluded right renal
artery, atrophic right kidney/iliac artery disease
- [**2156-4-2**]: DES to left lower renal artery, Bare metal stenting of
left middle renal artery, successful stenting of right common
iliac artery
- Bilateral subclavian stenosis. [**2156-12-27**]: s/p bilateral stenting
- [**2159-7-23**]: Bilateral Carotid Ultrasound:  Mild 1-39% bilateral
internal carotid artery stenosis without appreciable change from
prior carotid ultrasound
- [**2159-7-23**]: Bilateral Ankle/Arm Indices:  Ankle brachial index
data
continued to suggest normal arterial flow within both lower
extremities at rest without evidence of claudication criteria.
- [**2158-6-30**]:  90% ISR of right subclavian artery s/p angioplasty
and stenting
- Lower GIB due to an ulcer at age 18, none since
- CRI
- Claustrophobia
- Anxiety
- GERD
- Degenerative disc disease/back pain

MEDICATION ON ADMISSION: Oxycodone-Acetaminophen [**12-2**] TAB PO Q4H:PRN pain
    Acetaminophen 650 mg PO Q4H:PRN fever, pain
    Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO QID:PRN
    Simethicone 40-80 mg PO QID:PRN abdominal discomfort
    Aspirin 325 mg PO DAILY
    Amlodipine 5 mg PO/NG [**Hospital1 **]
    CloniDINE 0.1 mg PO BID
    Clopidogrel 75 mg PO/NG DAILY Start: In am
    Diltiazem Extended-Release 240 mg PO DAILY Start: In am
    Venlafaxine XR 75 mg PO DAILY Start: In am
    Pantoprazole 40 mg PO Q24H Start: In am
    Pravastatin 80 mg PO DAILY
    Ezetimibe 10 mg PO DAILY
    Valsartan 320 mg PO/NG DAILY
    Multivitamins 1 TAB PO/NG DAILY

ALLERGIES: Iodine; Iodine Containing / Flomax / Shellfish Derived

PHYSICAL EXAM: GENERAL: WNWD gentleman, lying still supine, in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. mmm
NECK: Supple with flat JVP.
CARDIAC:  RR, normal S1, S2. + systolic murmur @ LLSB no
radiation
LUNGS: No chest wall deformities. Respirations unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, extremely tender in right lower quadrant and
inguinal area, mild tenderness in right mid quadrant.
BACK: no ecchymosis of lower back, some mild tenderness of right
lower back
EXTREMITIES: No c/c/e. 2+ DP and PT pulses bilaterally.

FAMILY HISTORY: Father with hypertension.  DM2 in family. No known heart
attacks.

SOCIAL HISTORY: Per OMR notes, patient is married with three children.  He owns
a bread franchise.  His daughter [**Name (NI) 402**] [**Name (NI) **]
([**Telephone/Fax (1) 73318**]accompanied him to the procedure.
Tobacco: Patient had smoked 2ppd x 33 years. He quit in [**2155**]
ETOH: Socially;
Wife: [**Name (NI) **] [**Name (NI) **]: [**Telephone/Fax (1) 73319**] 

### Response:
{'Atherosclerosis of native arteries of the extremities with intermittent claudication,Accidental puncture or laceration during a procedure, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Degeneration of lumbar or lumbosacral intervertebral disc,Esophageal reflux,Anxiety state, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of peptic ulcer disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
