CHIEF COMPLAINT: Chest pain.

PRESENT ILLNESS: This is an 87 year old man with past medical history significant
for coronary artery disease with multiple stents to LCx and LAD,
diabetes, hypertension, who was admitted two months ago for GI
bleed and NSTEMI and now presents from OSH with chest pain.
This morning, he was using stationary bicycle at home for less
than five minutes when he developed burning substernal chest
pain [**9-13**], similar in quality to previous ischemic episodes.
Took 3 nitros with minimal relief and decided to go to hospital.
 At [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital ED, he was found to have TropI
5.02, BNP 2699; he was transferred by helicopter to [**Hospital1 18**] for
possible intervention.
.
In the ED at [**Hospital1 18**], T 99.9, HR 104, BP 150/68, RR 24, 96% on 3L
NC.  ECG notable for sinus tach with ST depression across
anterior precordium.  Initially pain free and plan was cath next
AM.  Patient then had return of chest pain with SBP in 80's.  No
change in EKG.  Taken to Cath lab emergently.
.
In cath lab [**10-26**]: LMCA was patent; LAD had 80% restenosis at
ostium; LCx had 100% in-stent restenosis.  DES was placed to L
main distal into the opening of LAD.  DES was also placed to
ostium/proximal LCx.  Right heart catheterization showed a wedge
pressure of 35.  PASP was 67. CI was 1.69.  He was transiently
on levophed and dopamine during the procedure and was
transferred from the cath to the CCU for further monitoring
.
Now in the CCU, patient denies lightheadedness; no palpitations.
 Now endorses CP [**4-13**], never fully disappeared during or after
cath.
.
Of note, he presented with CP in setting of GI bleed and NSTEMI
in [**2139-8-4**].  He had 100% occlusion of LCx stent; this was
balloon angioplastied.  There was also 70% occlusion of ostial
LAD; BMS was placed to this occlusion.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
Cardiac Risk Factors:
+ve Diabetes
+ve Dyslipidemia
+ve Hypertension
..
CARDIAC HISTORY:
CABG: None
Percutaneous coronary intervention: Multiple stents to LAD and
LCx most recent on [**8-23**]
Pacemaker/ICD: None
..
OTHER PAST HISTORY:
# Chronic obstructive pulmonary disease
# Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the ostial CX in 06, chronically occluded RCA.
Circumflex received a DES in [**2138**]. 2 DES to LAD in [**11-10**]
# Type II Diabetes ?? diet-controlled
# CRI baseline cr: 1.3-1.7
# Hypertension
# Hyperlipidemia
# Diverticulosis
# Peripherial vascular disease
# Peptic ulcer disease - EGD on [**2139-8-11**]

MEDICATION ON ADMISSION: # Simvastatin 80 mg QHS
# Ipratropium Bromide 17 mcg/Actuation Aerosol; 2 puffs QID
# Omeprazole 20 mg Tablet [**Hospital1 **]
# Clopidogrel 75 mg Tablet QDAY
# Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs q6H
# Aspirin 325 mg QDAY
# Captopril 12.5 mg [**Hospital1 **]
# Metoprolol Tartrate 12.5 mg [**Hospital1 **]
# Furosemide 80 mg [**Hospital1 **]
# Isosorbide 30 mg [**Hospital1 **]
# Allopurinol 300 mg QDAY

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM AT ADMISSION:
VITALS: T HR 110, BP 110/64, RR 16, 94% on 2L O2
GENERAL:  AAOx3, NAD, lying and speaking comfortably in bed
HEENT:  EOMI; PERRLA
NECK:  supple; no JVD appreciated
LUNGS:  scattered rhonchi and faint expiratory wheezes; no
crackles
HEART:  RRR; distant heart sounds; no murmurs
ABDOMEN:  obese; non-tender with normal bowel sounds; no HSM;
negative [**Doctor Last Name 515**] sign left and right sides
EXTREMITIES:  no pitting edema; skin hyperpigmentation over the
medial malleolus indicative of venous stasis disease
..
PHYSICAL EXAM AT DISCHARGE:

FAMILY HISTORY: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

SOCIAL HISTORY: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 20 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU.
Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypotension, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Right bundle branch block and left posterior fascicular block,Disorders of phosphorus metabolism,Anemia, unspecified,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Cyst of kidney, acquired,Esophageal reflux,Gout, unspecified
Subendo infarct, initial,Ac kidny fail, tubr necr,Chr systolic hrt failure,Hyposmolality,Atrial fibrillation,Chr kidney dis stage III,Hy kid NOS w cr kid I-IV,Chr airway obstruct NEC,Crnry athrscl natve vssl,Status-post ptca,Hypotension NOS,Adv eff medicinal NEC,Rt bbb/lft post fasc blk,Dis phosphorus metabol,Anemia NOS,Hyperlipidemia NEC/NOS,Periph vascular dis NOS,Peptic ulcer NOS,Cyst of kidney, acquired,Esophageal reflux,Gout NOS
Admission Date:  [**2139-10-26**]              Discharge Date:   [**2139-11-4**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain.

Major Surgical or Invasive Procedure:
Cardiac catheterization.


History of Present Illness:
This is an 87 year old man with past medical history significant
for coronary artery disease with multiple stents to LCx and LAD,
diabetes, hypertension, who was admitted two months ago for GI
bleed and NSTEMI and now presents from OSH with chest pain.
This morning, he was using stationary bicycle at home for less
than five minutes when he developed burning substernal chest
pain [**9-13**], similar in quality to previous ischemic episodes.
Took 3 nitros with minimal relief and decided to go to hospital.
 At [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital ED, he was found to have TropI
5.02, BNP 2699; he was transferred by helicopter to [**Hospital1 18**] for
possible intervention.
.
In the ED at [**Hospital1 18**], T 99.9, HR 104, BP 150/68, RR 24, 96% on 3L
NC.  ECG notable for sinus tach with ST depression across
anterior precordium.  Initially pain free and plan was cath next
AM.  Patient then had return of chest pain with SBP in 80's.  No
change in EKG.  Taken to Cath lab emergently.
.
In cath lab [**10-26**]: LMCA was patent; LAD had 80% restenosis at
ostium; LCx had 100% in-stent restenosis.  DES was placed to L
main distal into the opening of LAD.  DES was also placed to
ostium/proximal LCx.  Right heart catheterization showed a wedge
pressure of 35.  PASP was 67. CI was 1.69.  He was transiently
on levophed and dopamine during the procedure and was
transferred from the cath to the CCU for further monitoring
.
Now in the CCU, patient denies lightheadedness; no palpitations.
 Now endorses CP [**4-13**], never fully disappeared during or after
cath.
.
Of note, he presented with CP in setting of GI bleed and NSTEMI
in [**2139-8-4**].  He had 100% occlusion of LCx stent; this was
balloon angioplastied.  There was also 70% occlusion of ostial
LAD; BMS was placed to this occlusion.

Past Medical History:
PAST MEDICAL HISTORY:
Cardiac Risk Factors:
+ve Diabetes
+ve Dyslipidemia
+ve Hypertension
..
CARDIAC HISTORY:
CABG: None
Percutaneous coronary intervention: Multiple stents to LAD and
LCx most recent on [**8-23**]
Pacemaker/ICD: None
..
OTHER PAST HISTORY:
# Chronic obstructive pulmonary disease
# Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the ostial CX in 06, chronically occluded RCA.
Circumflex received a DES in [**2138**]. 2 DES to LAD in [**11-10**]
# Type II Diabetes ?? diet-controlled
# CRI baseline cr: 1.3-1.7
# Hypertension
# Hyperlipidemia
# Diverticulosis
# Peripherial vascular disease
# Peptic ulcer disease - EGD on [**2139-8-11**]

Social History:
Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 20 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU.

Family History:
Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

Physical Exam:
PHYSICAL EXAM AT ADMISSION:
VITALS: T HR 110, BP 110/64, RR 16, 94% on 2L O2
GENERAL:  AAOx3, NAD, lying and speaking comfortably in bed
HEENT:  EOMI; PERRLA
NECK:  supple; no JVD appreciated
LUNGS:  scattered rhonchi and faint expiratory wheezes; no
crackles
HEART:  RRR; distant heart sounds; no murmurs
ABDOMEN:  obese; non-tender with normal bowel sounds; no HSM;
negative [**Doctor Last Name 515**] sign left and right sides
EXTREMITIES:  no pitting edema; skin hyperpigmentation over the
medial malleolus indicative of venous stasis disease
..
PHYSICAL EXAM AT DISCHARGE:


Pertinent Results:
LAB RESULTS AT ADMISSION:
..
[**2139-10-26**] 09:06PM   GLUCOSE-187* UREA N-64* CREAT-2.5* SODIUM-133
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
[**2139-10-26**] 09:06PM   PLT COUNT-225
[**2139-10-26**] 06:59PM   TYPE-ART PO2-73* PCO2-32* PH-7.44 TOTAL
CO2-22 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-2L NP
[**2139-10-26**] 06:59PM   O2 SAT-93
[**2139-10-26**] 03:00PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2139-10-26**] 03:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2139-10-26**] 03:00PM URINE  RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
[**2139-10-26**] 03:00PM URINE  HYALINE-25*
[**2139-10-26**] 03:00PM URINE  MUCOUS-RARE
[**2139-10-26**] 02:35PM   LACTATE-2.4*
[**2139-10-26**] 02:20PM   GLUCOSE-158* UREA N-64* CREAT-2.6* SODIUM-134
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-23 ANION GAP-19
[**2139-10-26**] 02:20PM   estGFR-Using this
[**2139-10-26**] 02:20PM   CK(CPK)-134
[**2139-10-26**] 02:20PM   CK-MB-17* MB INDX-12.7*
[**2139-10-26**] 02:20PM   cTropnT-1.20*
[**2139-10-26**] 02:20PM   CALCIUM-9.2 PHOSPHATE-4.7*# MAGNESIUM-2.5
[**2139-10-26**] 02:20PM   WBC-19.6* RBC-4.19* HGB-11.9* HCT-36.2*
MCV-86 MCH-28.5 MCHC-33.0 RDW-15.6*
[**2139-10-26**] 02:20PM   NEUTS-92.4* LYMPHS-3.5* MONOS-3.9 EOS-0.2
BASOS-0
[**2139-10-26**] 02:20PM   PT-17.3* PTT-117.4* INR(PT)-1.6*
..
STUDIES:
.
EKG: NSR 100 with PACs.  RBBB with LAFB.  Diffuse ST-segment
depression in leads V1-V5.  TWI in I and aVL.
.
CORONARY CATHETERIZATION ([**2139-10-26**]):
1. Successful stenting of the ostial LAD restenosis with a
3.0x16mm
Taxus stent that was postdilated to 3.5mm. Final angiography
revealed no
residual stenosis, no angiogrpahically apparent dissection and
TIMI 3
flow (see PTCA comments).
2. Successful stenting of the ostial LCX restenosis with a
2.5x12mm
Taxus and a 3.0x8mm Taxus stents in overlapping fashion. Final
angiography revealed little residual stenosis, no
angiographically
apparent dissection and TIMI 3 flow (see PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal ventricular function.
3. Successful stenting of the LAD and LCX.
.
TRANSTHORACIC ECHOCARDIOGRAM ([**2139-10-28**]):
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
No masses or thrombi are seen in the left ventricle. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %) with inferior and infero-lateral akinesis. The remaining
segments are hypokinetic. There is no ventricular septal defect.
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
RIGHT GROIN DOPPLER ULTRASOUND ([**2139-10-28**]):
FINDINGS: Views of the right groin demonstrate a patent common
femoral artery and common femoral vein with adequate
wall-to-wall flow. There is no evidence of a pseudoaneurysm,
hematoma, or arteriovenous fistula.
.
RENAL ULTRASOUND ([**2139-10-29**]):
FINDINGS: The right kidney measures 11.5 cm and the left kidney
measures 11.3 cm. There is no hydronephrosis and no stones or
solid masses are identified in either kidney. A simple cyst is
seen in the lower pole of the right kidney measuring 3.6 x 4.4 x
3.2 cm.
DOPPLER EXAMINATION: Note is made that this is a limited study
due to the
patient's body habitus and the patient's ability to hold his
breath. Color
Doppler and pulse-wave Doppler images were obtained. Arterial
waveforms of
the main renal arteries bilaterally demonstrate sharp upstrokes.
RIs of the
intraparenchymal arteries in the right kidney range from
0.69-0.80. RIs of
the intraparenchymal arteries of the left kidney range from
0.73-0.76.
Appropriate flow is seen in the main renal vein bilaterally.
IMPRESSION:
1. No hydronephrosis and no renal stones identified. Simple
4.4-cm right
renal cyst.
2. Within the technical limits of the examination there is no
evidence of
renal artery stenosis.

Brief Hospital Course:
In summary, this is an 87 year old man with PMHx of CAD with
multiple stents most recently to proximal LAD and angioplasty of
ostial LCx in [**2139-8-4**] presents with exertional substernal
chest pain not responsive to nitrate, positive troponins, and
ST-segment depressions indicative of antero-lateral ischemia.
Now s/p PTCA and DES to LAD and LCx, admitted to the CCU for
closer monitoring.
..
# CAD/ISCHEMIA:  He went straight to the cath lab and had DES
placed to his left circumflex and left anterior descending
arteries.  Post-procedure, his chest pain gradually improved and
he was continued on aspirin, Plavix, and Integrillin.  The
Integrillin was stopped after 18 hours. During the rest of his
stay Mr. [**Known lastname **] was continued on Aspirin, Plavix, Simvastatin and
a Beta Blocker.
..
# PUMP:  His most recent TTE at time of admission showed an LVEF
of 40% with regional left ventricular systolic dysfunction
consistent with coronary artery disease.  After the heart attack
and catheterization repeat echo showed EF of 30%.
Post-procedure, physical exam and oxygen requirements indicated
that he was slightly volume overloaded.  He was diuresed with IV
Lasix, then Lasix drip for about two days at which point his UOP
decreased and his creatinine began to rise.  The Lasix was
stopped he was kept even. His SBP remained in the mid 90s to
100s throughout his hospitalization.
.
As noted, he was continued on metoprolol and ACEI was held due
to acute renal failure.
..
# RHYTHM:  During this hospitalization he developed new atrial
fibrillation.  His ventricular rate was well controlled w/
metoprolol.  He was started on amiodorone with the goal to
convert him back to normal sinus rhythm.  Anticoagulation was
started with heparin and bridged to coumadin. At time of
discharge the patient was on 2.5 mg Coumadin daily and INR was
1.6, Heparin had been continued until discharge. The patient was
instructed to follow-up the day after discharge with his PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], to follow his continued Warfarin monitoring and INR
checks with the therapeutic goal of [**3-8**] INR. The patient had
better controlled atrial fibrillation but was still having less
frequent, asymptomatic atrial fibrillation on telemetry with
evidence of fascicular block and bradycardia. He denied any
chest pain, palpitations, dizziness or shortness of breath at
the time of discharge. He will plan to continue rhythm control
with 200mg daily of Amiodarone. Given the patient's bradycardia
he will hold his beta blocker, Metoprolol, for now and he will
follow-up with his PCP and Dr. [**Last Name (STitle) **] regarding restarting this
medication. He will continue telemonitoring on [**Hospital3 4298**]
with the services of local VNA.
..
# ACUTE ON CHRONIC RENAL FAILURE:  He has chronic kidney disease
with a baseline creatinine of 1.4 to 1.7, elevated at time of
admission to 2.6 likely due to hypoperfusion in the setting of
NSTEMI and low-cardiac output.  He was treated pre and post-cath
with sodium bicarbonate and n-acetylcytsteine.  However, after
the procedure his creatinine continued to rise.  A renal
ultrasound was negative for obstruction or hydronephrosis.
Urine electrolytes were indicative of prerenal azotemia.  Urine
eosinophils were negative.  There were granular casts on
urinalysis which indicated ATN. A renal consult corroborated
this diagnosis.  His ACEI was held, as above, and his Is/Os were
kept even given the concern of hypovolemia and renal
hypoperfusion. Mr. [**Known lastname 26785**] Cr eventually plateaud and began to
trend down and fortunately he did not need any dialysis
intervention. At time of discharge the patient's BUN was 92 and
Cr 3.2. The patient's baseline Cr is 1.7 range. The patient was
instructed to follow-up with a local nephrologist in [**Location (un) 7453**] regarding a renal follow up over the coming 1-2 weeks
time. Dr. [**Last Name (STitle) **], Mr. [**Known lastname 26785**] PCP, [**Name10 (NameIs) **] also continue to monitor
the patient's electrolytes and renal funtion as well. The
patient's Allopurinol dose was renally adjusted to 100mg daily.

..
# RIGHT AV FISTULA: This was seen on cardiac catheterization and
subsequently not seen on duplex ultrasound.  Vascular is
involved and he will need follow-up with Dr. [**Last Name (STitle) **] in 6 to
8 weeks.
..
# DM:  He was given a diabetic diet and insulin sliding scale.
..
# COPD:  We continued his home albuterol and ipratropium.
..
# GERD:  We continued his home PPI at twice daily dosing.
..
# GOUT:  We continued his home allopurinol at decreased dose due
to development of acute renal failure.
..
During the hospitalization, he was kept on a diabetic and
heart-healthy diet.  DVT prophylaxis was achieved first with
heparin subQ, and when he developed atrial fibrillation he was
started on heparin drip and bridged to warfarin.  GI
prophylaxis, as above, with PPI twice daily.  His code status
was full code throughout his hospital stay.

Medications on Admission:
# Simvastatin 80 mg QHS
# Ipratropium Bromide 17 mcg/Actuation Aerosol; 2 puffs QID
# Omeprazole 20 mg Tablet [**Hospital1 **]
# Clopidogrel 75 mg Tablet QDAY
# Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs q6H
# Aspirin 325 mg QDAY
# Captopril 12.5 mg [**Hospital1 **]
# Metoprolol Tartrate 12.5 mg [**Hospital1 **]
# Furosemide 80 mg [**Hospital1 **]
# Isosorbide 30 mg [**Hospital1 **]
# Allopurinol 300 mg QDAY

Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNS

Discharge Diagnosis:
Acute Renal Failure / Acute Tubular Necrosis
Non ST elevation myocardial infarction
Systolic congestive heart failure
Atrial fibrillation


Discharge Condition:
stable
Hct:30.4
Bun:92
creat:3.2


Discharge Instructions:
You had a heart attack with drug eluting stents to two coronary
arteries to repair a narrowing. Your kidneys were not working
very well so we adjusted your medicines. Your heart is weak so
you are on medicines to help it pump better (metoprolol and
captopril) You have a tendency to retain fluid so please weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6
pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 2000cc
You have a heart rhythm irregularity called atrial fibrillation.
We are controlling your heart rate with metoprolol and
amiodarone and preventing strokes with coumadin. For now, please
do not take your Metoprolol until you follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) **].
.
New medicines:
warfarin ( a blood thinner)
amiodarone( to slow your heart rate)
Metoprolol Succinate (a long acting medicine to slow your heart
rate)

Your usual Allopurinol dose was decreased to 100mg daily due to
your renal impairment. Please continue to take this dose until
your PCP informs you that your renal function is back to normal.


Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble
breathing, fluid accumulating in your arms or legs, a new cough
or nausea. For now, please do not take your Metoprolol until you
follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. You may need to take some
Lasix to help you to promote additional urine production but
this will be discussed at your follow-up appointment with Dr.
[**Last Name (STitle) **].

Followup Instructions:
Primary care:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 29822**] Date/Time: Friday
[**11-6**] at 11:45am.
.
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 5455**] Date/Time:
Please call to make a follow-up appointment with Dr. [**Last Name (STitle) **] in [**4-7**]
weeks time

Nephrology: Please follow-up with Nephrologist in [**Location (un) **],
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 15170**] at [**Telephone/Fax (1) 19657**] within the next week

Vascular Department -please follow-up with Dr. [**Last Name (STitle) **] in [**7-12**]
weeks time . Office phone # [**Telephone/Fax (1) 3121**]



Completed by:[**2139-11-4**]

Name:  [**Known lastname **],[**Known firstname 7138**] V                 Unit No:   [**Numeric Identifier 7139**]

Admission Date:  [**2139-10-26**]              Discharge Date:   [**2139-11-4**]

Date of Birth:  [**2052-6-5**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 276**]
Addendum:
Addendum to discharge summary [**2139-11-4**] to note that Mr. [**Known lastname **] was
set up for a follow-up appointment with Dr. [**Last Name (STitle) 274**] on [**2139-12-2**] at 1pm for a repeat echo and general follow-up for atrial
fibrillation and recent MI. Patient and family made aware of
this prior to discharge and given phone number for Dr.[**Name (NI) 7140**]
office in case patient needs to contact Dr. [**Last Name (STitle) 274**] sooner
([**Telephone/Fax (1) 7141**]).

[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7142**], M.D.

Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNS

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 284**] MD [**MD Number(1) 285**]

Completed by:[**2139-11-4**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypotension, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Right bundle branch block and left posterior fascicular block,Disorders of phosphorus metabolism,Anemia, unspecified,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Cyst of kidney, acquired,Esophageal reflux,Gout, unspecified'}


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: This is an 87 year old man with past medical history significant
for coronary artery disease with multiple stents to LCx and LAD,
diabetes, hypertension, who was admitted two months ago for GI
bleed and NSTEMI and now presents from OSH with chest pain.
This morning, he was using stationary bicycle at home for less
than five minutes when he developed burning substernal chest
pain [**9-13**], similar in quality to previous ischemic episodes.
Took 3 nitros with minimal relief and decided to go to hospital.
 At [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] Hospital ED, he was found to have TropI
5.02, BNP 2699; he was transferred by helicopter to [**Hospital1 18**] for
possible intervention.
.
In the ED at [**Hospital1 18**], T 99.9, HR 104, BP 150/68, RR 24, 96% on 3L
NC.  ECG notable for sinus tach with ST depression across
anterior precordium.  Initially pain free and plan was cath next
AM.  Patient then had return of chest pain with SBP in 80's.  No
change in EKG.  Taken to Cath lab emergently.
.
In cath lab [**10-26**]: LMCA was patent; LAD had 80% restenosis at
ostium; LCx had 100% in-stent restenosis.  DES was placed to L
main distal into the opening of LAD.  DES was also placed to
ostium/proximal LCx.  Right heart catheterization showed a wedge
pressure of 35.  PASP was 67. CI was 1.69.  He was transiently
on levophed and dopamine during the procedure and was
transferred from the cath to the CCU for further monitoring
.
Now in the CCU, patient denies lightheadedness; no palpitations.
 Now endorses CP [**4-13**], never fully disappeared during or after
cath.
.
Of note, he presented with CP in setting of GI bleed and NSTEMI
in [**2139-8-4**].  He had 100% occlusion of LCx stent; this was
balloon angioplastied.  There was also 70% occlusion of ostial
LAD; BMS was placed to this occlusion.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
Cardiac Risk Factors:
+ve Diabetes
+ve Dyslipidemia
+ve Hypertension
..
CARDIAC HISTORY:
CABG: None
Percutaneous coronary intervention: Multiple stents to LAD and
LCx most recent on [**8-23**]
Pacemaker/ICD: None
..
OTHER PAST HISTORY:
# Chronic obstructive pulmonary disease
# Coronary artery disease s/p PCI with LAD stent [**2126**], [**2129**].
Cypher stent to the ostial CX in 06, chronically occluded RCA.
Circumflex received a DES in [**2138**]. 2 DES to LAD in [**11-10**]
# Type II Diabetes ?? diet-controlled
# CRI baseline cr: 1.3-1.7
# Hypertension
# Hyperlipidemia
# Diverticulosis
# Peripherial vascular disease
# Peptic ulcer disease - EGD on [**2139-8-11**]

MEDICATION ON ADMISSION: # Simvastatin 80 mg QHS
# Ipratropium Bromide 17 mcg/Actuation Aerosol; 2 puffs QID
# Omeprazole 20 mg Tablet [**Hospital1 **]
# Clopidogrel 75 mg Tablet QDAY
# Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs q6H
# Aspirin 325 mg QDAY
# Captopril 12.5 mg [**Hospital1 **]
# Metoprolol Tartrate 12.5 mg [**Hospital1 **]
# Furosemide 80 mg [**Hospital1 **]
# Isosorbide 30 mg [**Hospital1 **]
# Allopurinol 300 mg QDAY

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM AT ADMISSION:
VITALS: T HR 110, BP 110/64, RR 16, 94% on 2L O2
GENERAL:  AAOx3, NAD, lying and speaking comfortably in bed
HEENT:  EOMI; PERRLA
NECK:  supple; no JVD appreciated
LUNGS:  scattered rhonchi and faint expiratory wheezes; no
crackles
HEART:  RRR; distant heart sounds; no murmurs
ABDOMEN:  obese; non-tender with normal bowel sounds; no HSM;
negative [**Doctor Last Name 515**] sign left and right sides
EXTREMITIES:  no pitting edema; skin hyperpigmentation over the
medial malleolus indicative of venous stasis disease
..
PHYSICAL EXAM AT DISCHARGE:

FAMILY HISTORY: Brother with hemorrhagic CVA [**3-7**] aneurysm; father with HTN;
brother had "[**Last Name **] problem", sister had ovarian cancer.

SOCIAL HISTORY: Retired gunsmith. Lives with wife on MV. Prior alcoholic, last
drink 20 years ago. Smoked 2 ppd x 50 years; quit 15 years
prior. No IVDU. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Chronic systolic heart failure,Hyposmolality and/or hyponatremia,Atrial fibrillation,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Hypotension, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Right bundle branch block and left posterior fascicular block,Disorders of phosphorus metabolism,Anemia, unspecified,Other and unspecified hyperlipidemia,Peripheral vascular disease, unspecified,Peptic ulcer of unspecified site, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction,Cyst of kidney, acquired,Esophageal reflux,Gout, unspecified'}
