CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: The patient is a 76-year-old female transferred from the [**First Name4 (NamePattern1) 3075**]
[**Last Name (NamePattern1) 3549**] Hospital ER on the evening of [**2139-11-4**] with chest pain
radiating to her right posterior shoulder area. Initial EKG had
some non-specific ST changes concerning for NSTEMI and EF per
ECHO (TTE) done at OSH noted to be 15%.  Per outside hospital
records the patient had reported that her pain was relieved
after SL nitroglycerin tablets x 3 and Lopressor 5mg IV x 3. She
was also given a loading dose of Plavix 600mg in the ER and 75mg
the following morning and she was started on both Integrillin
and Heparin and was transferred directly to the cardiac
catheterization lab at [**Hospital1 18**] and found to not have any
obstructive coronary disease, LV-gram showing EF closer to 30%
but prominent apical ballooning consistent with Takotsubo's
Cardiomyopathy presentation. She began to have severe
hypotension during her cardiac catheterization and was started
on Dopamine then switched to Neosynephrine. She was noted to
have an expanding right groin. Of note, given reported
difficulty obtaining access initially thought was that she was
having a iatrogenic bleed.
.
In the operating room the patient was continued on
Neosynephrine, and had a right internal jugular central venous
line placed and failed attempt at a radial arterial line.
Intubation was uncomplicated. The patient was also given a total
of 3.5L of NS and 2 Units blood were given. Just prior to going
to the operating room with the vascular surgery team the patient
was also given IVFs and 2 Units of blood in cardiac
catheterization lab. Thus, she received in total, 4 Units of
blood before transfer up to CCU post-operatively. She was able
to be slowly weaned off of Neosynephrine and BP was 115/70 upon
presentation to the CCU. Per vascular team, the inferior
epigastric artery on the right was ligated and a hematoma was
evacuated, removing roughly 500cc of blood. Pressure dressing
was applied. Patient arrived to the CCU intubated and sedated
and a few continued bouts of intermittent low blood pressures.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: negative for Diabetes, no significant
dyslipidemia, but positive for age, hypertension, sedentary
lifestyle
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None / No priors
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Glaucoma
Osteoporosis
Cataracts

MEDICATION ON ADMISSION: Home Medications:
Dorzolamide-Timolol 2-0.5 % eye drops tid
Travatan 0.004 % eye drops qhs
Lisinopril 5mg daily
Occasional OTC Tylenol
.
Medications on Admission:
Heparin drip and Integrilin started [**11-4**] but discontinued in
setting of acute bleed on [**11-5**] (off both at CCU transfer time)
-plavix 600mg [**11-4**], 75mg [**11-5**]
-lopressor 25mg po .
-lipitor 40mg
-nitro paste 1 inch q 4 hours
-cosopt eye gtts
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: No known family history of significant CAD, premature coronary
artery disease or sudden death.

SOCIAL HISTORY: The patient is married and lives in [**Location 1110**] with her husband. She
has one daughter who lives locally. In terms of recent stressors
the patient reports some anxiety regarding an upcoming Glaucoma
surgery and some additional stress and residual grief as she
learned that her brother died several months ago.
Takotsubo syndrome,Cardiogenic shock,Hematoma complicating a procedure,Acute combined systolic and diastolic heart failure,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Other iatrogenic hypotension,Unspecified glaucoma,Osteoporosis, unspecified,Unspecified essential hypertension
Takotsubo syndrome,Cardiogenic shock,Hematoma complic proc,Ac syst/diastol hrt fail,Acc cut/hem w heart cath,Iatrogenc hypotnsion NEC,Glaucoma NOS,Osteoporosis NOS,Hypertension NOS
Admission Date:  [**2139-11-5**]              Discharge Date:   [**2139-11-9**]

Date of Birth:  [**2063-8-13**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
1. Cardiac Catheterization
2. Emergent vascular surgery with ligation of inferior
epigastric artery and evacuation of right groin/pelvic hematoma

History of Present Illness:
The patient is a 76-year-old female transferred from the [**First Name4 (NamePattern1) 3075**]
[**Last Name (NamePattern1) 3549**] Hospital ER on the evening of [**2139-11-4**] with chest pain
radiating to her right posterior shoulder area. Initial EKG had
some non-specific ST changes concerning for NSTEMI and EF per
ECHO (TTE) done at OSH noted to be 15%.  Per outside hospital
records the patient had reported that her pain was relieved
after SL nitroglycerin tablets x 3 and Lopressor 5mg IV x 3. She
was also given a loading dose of Plavix 600mg in the ER and 75mg
the following morning and she was started on both Integrillin
and Heparin and was transferred directly to the cardiac
catheterization lab at [**Hospital1 18**] and found to not have any
obstructive coronary disease, LV-gram showing EF closer to 30%
but prominent apical ballooning consistent with Takotsubo's
Cardiomyopathy presentation. She began to have severe
hypotension during her cardiac catheterization and was started
on Dopamine then switched to Neosynephrine. She was noted to
have an expanding right groin. Of note, given reported
difficulty obtaining access initially thought was that she was
having a iatrogenic bleed.
.
In the operating room the patient was continued on
Neosynephrine, and had a right internal jugular central venous
line placed and failed attempt at a radial arterial line.
Intubation was uncomplicated. The patient was also given a total
of 3.5L of NS and 2 Units blood were given. Just prior to going
to the operating room with the vascular surgery team the patient
was also given IVFs and 2 Units of blood in cardiac
catheterization lab. Thus, she received in total, 4 Units of
blood before transfer up to CCU post-operatively. She was able
to be slowly weaned off of Neosynephrine and BP was 115/70 upon
presentation to the CCU. Per vascular team, the inferior
epigastric artery on the right was ligated and a hematoma was
evacuated, removing roughly 500cc of blood. Pressure dressing
was applied. Patient arrived to the CCU intubated and sedated
and a few continued bouts of intermittent low blood pressures.

Past Medical History:
1. CARDIAC RISK FACTORS: negative for Diabetes, no significant
dyslipidemia, but positive for age, hypertension, sedentary
lifestyle
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None / No priors
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Glaucoma
Osteoporosis
Cataracts


Social History:
The patient is married and lives in [**Location 1110**] with her husband. She
has one daughter who lives locally. In terms of recent stressors
the patient reports some anxiety regarding an upcoming Glaucoma
surgery and some additional stress and residual grief as she
learned that her brother died several months ago.

She denies any smoking history /tobacco use. She drinks
approximately 5 glasses of wine per week and denies any other
illicit drug use.

Family History:
No known family history of significant CAD, premature coronary
artery disease or sudden death.

Physical Exam:
On admission:

Vital Signs: 98.2F, BP 115/70 HR 70s, O2 100% on AC ventilation
550x14, PEEP of 5 and FiO2 of 100%. CVP 11

GENERAL: Intubated and sedated. responds to painful stimuli and
moving all 4 extremities.
HEENT: PERRLA bilaterally, sclera anicteric and EOMI, moist
mucosal membranes
CARDIAC: S1/S2 regular, no murmurs, rubs or gallops appreciated,
 soft heart sounds noted, 2+ carotid upstrokes
LUNGS: No tracheal deviation, CTA bilaterally anteriorly and
laterally
ABDOMEN: Soft, nontender and nondistended. No HSM. Abdomnal
aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: Right groin with thick pressure dressing, no
ecchymoses or tense areas noted
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: diminished 1+ radial pulses bilaterally, DP and PT
pulses are measured by doppler, PT pulses 1+ and palpable but
DPs difficult to palpate

Pertinent Results:
[**2139-11-5**] 07:24PM   TYPE-MIX PO2-29* PCO2-40 PH-7.24* TOTAL
CO2-18* BASE XS--10
[**2139-11-5**] 07:24PM   LACTATE-1.5
[**2139-11-5**] 07:24PM   O2 SAT-52
[**2139-11-5**] 06:35PM   GLUCOSE-178* UREA N-27* CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-118* TOTAL CO2-18* ANION GAP-7*
[**2139-11-5**] 06:35PM   estGFR-Using this
[**2139-11-5**] 06:35PM   CK(CPK)-189*
[**2139-11-5**] 06:35PM   CK-MB-27* MB INDX-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM   CALCIUM-6.8* PHOSPHATE-3.1 MAGNESIUM-1.2*
[**2139-11-5**] 06:35PM   WBC-15.1*# RBC-3.79*# HGB-11.2*# HCT-32.5*#
MCV-86# MCH-29.6 MCHC-34.5 RDW-14.9
[**2139-11-5**] 06:35PM   NEUTS-90.7* LYMPHS-5.5* MONOS-3.6 EOS-0.1
BASOS-0.1
[**2139-11-5**] 06:35PM   I-HOS-D
[**2139-11-5**] 06:35PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2139-11-5**] 06:35PM   PLT SMR-LOW PLT COUNT-87*#
[**2139-11-5**] 06:35PM   PT-15.7* PTT-47.5* INR(PT)-1.4*
[**2139-11-5**] 06:35PM   FIBRINOGE-111*
[**2139-11-5**] 05:54PM   TYPE-CENTRAL VE PO2-66* PCO2-48* PH-7.14*
TOTAL CO2-17* BASE XS--12
[**2139-11-5**] 05:20PM   TYPE-ART PO2-341* PCO2-43 PH-7.14* TOTAL
CO2-15* BASE XS--14
[**2139-11-5**] 05:20PM   HGB-11.2* calcHCT-34
[**2139-11-5**] 05:20PM   GLUCOSE-309* LACTATE-4.0* NA+-133* K+-5.7*
CL--113*
[**2139-11-5**] 03:28PM   TYPE-ART O2-100 PO2-434* PCO2-30* PH-7.38
TOTAL CO2-18* BASE XS--5 AADO2-267 REQ O2-50 INTUBATED-NOT
INTUBA
[**2139-11-5**] 03:28PM   GLUCOSE-205* LACTATE-1.5 K+-4.4
[**2139-11-5**] 03:00PM   WBC-7.2 RBC-2.17*# HGB-6.9*# HCT-20.3*#
MCV-94 MCH-32.1* MCHC-34.3 RDW-14.3
[**2139-11-5**] 02:49PM   TYPE-ART O2 FLOW-2 PO2-94 PCO2-37 PH-7.32*
TOTAL CO2-20* BASE XS--6 COMMENTS-NASAL [**Last Name (un) 154**]

[**2139-11-5**] CARDIAC CATHETERIZATION RESULTS:
LMCA mild plaquing, LAD 20% origin, LCX patent, mid-RCA with
mild 25% diffuse plaquing. LV gram showing some MR, EF 30%,
bases intact, severe hypokinesis of anterolateral, apical and
inferior walls, bedside echo without pericardial effusion, no
LVOT gradient, depressed EF.
.
HEMODYNAMICS:
RA 4, RV 23/0
PCW mean 4
PA 15/4
Aorta 95/75, MAP 80
post angio:
PCW mean 7, PA 28/9
LV 134
Aorta 134/86
Cardiac index 1.32 pre angio, 1.30 post angio
Art sat 98%, SVC saturation 49%, PA sat 40%
.
[**2139-11-5**] ECHO: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. The overall LV ejection
fraction appears moderately-to-severely depressed secondary to
extensive apical akinesis , and severe hypokinesis of the
anterior septum. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no pericardial effusion.
Overall impression is severe anteroseptal hypokinesis/akinesis,
LVEF = 30%.
.
[**2139-11-7**] REPEAT ECHO: The left atrium is normal in size. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV systolic function appears
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to akinesis of the anterior septum and anterior free
wall; there is extensive apical akinesis with focal dyskinesi..
Right ventricular chamber size and free wall motion are normal.
The aortic arch is moderately dilated. There are focal
calcifications in the aortic arch. 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. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. Compared with the findings of the prior study (images
reviewed) of [**2139-11-5**], the findings are similar.
.
[**2139-11-5**] EKG:  NSR, rate 60, normal axis and intervals, poor R
wave progression, no acute ST elevations or prominent
depressions.
.
[**2139-11-6**] EKG : Rate 80s, normal sinus rhythm, delayed R wave
transition. Q-T interval prolongation with QT/QTc = 430/472.
Significant resolution of the T wave abnormalities since
admission.
.
[**2139-11-6**] CXR: Right internal jugular catheter ends in the mid
SVC, mild bibasilar atelectasis, volume overload decreased, no
consolidations or effusions
 .
[**2139-11-7**] EKG: Rate 90, Normal sinus rhythm, some
intraventricular conduction delay, poor R wave progression,
nonspecific inferolateral T wave flattening and low limb lead
voltages, Q-T interval appears shorter
.
[**2139-11-7**] LIPID PROFILE: Total Chol 83, Triglyc-147, HDL-26
CHOL/HD-3.2 LDLcalc-28
ADDITIONAL POST-ADMISSION LABS:
[**2139-11-6**] 05:22AM BLOOD CK-MB-28* MB Indx-14.4* cTropnT-0.41*
[**2139-11-5**] 06:35PM BLOOD CK-MB-27* MB Indx-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM BLOOD CK(CPK)-189*
[**2139-11-6**] 05:22AM BLOOD CK(CPK)-194*
[**2139-11-7**] 03:49AM BLOOD ALT-9 AST-24 AlkPhos-29* TotBili-1.2
[**2139-11-8**] 01:19PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2139-11-9**] 06:25AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.3* Hct-29.6*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.5 Plt Ct-133*, Glucose-98
UreaN-19 Creat-0.7 Na-143 K-4.1 Cl-114* HCO3-24 AnGap-9, Mg-2.0


Brief Hospital Course:
ASSESSMENT AND PLAN [**2139-11-6**] :
In summary, patient is a 76-year-old female with a past medical
history of hypertension and glaucoma who presented to her local
ED after several hours of chest "discomfort" and mid-sternal
chest pain with some radiation to her right shoulder which was
relieved after nitroglycerin and Lopressor at OSH. Initial EKG
had
some non-specific ST changes concerning for NSTEMI with possible
cardiogenic shock given EF per ECHO report at OSH noted to be
15%. Repeat ECHO and cardiac catheterization of [**Hospital1 18**] showed
findings consistent with Takotsubo's cardiomyopathy and very
scant evidence of coronary artery disease. Unfortunately the
patient's cardiac catheterization was complicated by a large
right groin hematoma and acute onset of hypotension. Inferior
epigastric artery required emergent ligation by the [**Hospital1 18**]
vascular surgery team and the patient also had about 500cc blood
evacuated from hematoma site.
.
CARDIAC PUMP FUNCTION /TAKOTSUBO CARDIOMYOPATHY: The patient's
heart had classic apical ballooning on ECHO and typical
presentation of Takotsubo's cardiomyopathy. Repeat ECHO [**2139-11-5**]
showing LVEF 30% (at OSH EF 15%). Per patient's spouse she had
been under stress lately regarding the death of a sibling and
her upcoming glaucoma surgery. Upon CCU arrival the patient's
blood pressure had been challenged in the setting of a recent
post-catheterization arterial bleed as noted below. However, she
had been resuscitated with over 5L IVFs and given 4 Units Blood
throughout the day leading up to CCU transfer and her BP had
stabilized to SBPs in the 90s range. An A-line was placed for
more accurate hemodynamic monitoring and the patient had been
weaned off of her pressors prior to CCU presentation. By
hospital day 2 the patient had SBPs in the low 100-110 range and
MAPs were consistently > 65 range. She had minimal crackles on
lung exam. She was given 10mg IV Lasix to optimize extubation on
CCU day 2 which she tolerated well. Fentanyl and Versed were
weaned down and RSBIs were in 50 range. She was successfully
extubated with no complications and by hospital day 3 she had
progressed to 95-99%on 2L NC and then she was weaned to room air
with no residual  shortness of breath complaints. On [**2139-11-7**]
repeat ECHO was largely unchanged and EF still 30%. The team
ultimately decided not to maintain the patient on
anticoagulation for her apical enlargement/thrombus risk given
the recent setting of her acute hematoma and hemorrhage.
Moreover, the data on anticoagulation and thrombus/stroke
reduction rates in Takotsubo population is lacking and no clear
recommendations exist.
.
Additional cardiomyopathy etiologies were explored which
included a work-up sent off for TSH, lipid profile and iron
studies (hemochromatosis). Iron Saturation level was 63%,
however in setting of acute event iron studies were felt to be
unreliable. Given that Mrs. [**Known lastname 75808**] has no past medical history
of diabetes (HgAIC 5.5)and limited PMH in general
hemochromatosis is unlikely but she was encouraged to discuss
repeat iron studies at a later date with her PCP as an
outpatient. She was also found to have a borderline high TSH
which is also unreliable in acute setting and she will plan to
follow-up with her PCP on this issue.
.
Once the patient's blood pressure and hematocrits had stabilized
she was placed on additional 25mg daily Toprol XL and her home
dose of 5mg Lisinopril was restarted. She will plan for a repeat
ECHO in [**3-24**] weeks and a follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
.
CORONARIES: The patient had very minimal CAD on cardiac
catheterization with 20% LAD and mild 25% RCA plaques. ST
changes were very non-specific on EKGs and did not reveal
classic ACS presentation for STEMI or NSTEMI. The patient was
monitored telemetry in the CCU and she had no additional bout of
chest pain, shortness of breath, palpitations or lightheadedness
during her hospital stay. The patient's minimal bump in cardiac
enzymes (CK 180-190 range, Troponin peak of 0.60) was attributed
to mild ischemia/microvascular stress in setting oh her
Takotsubo cardiomyopathy. Aspirin therapy was initially held in
the setting of her recovery from an acute bleed but she was
advised to begin taking 81mg of Aspirin daily at time of
discharge. Lipid profile was likely inaccurate in acute illness
setting but showed no hyperlipidemia. She will plan to have a
repeat lipid panel as an outpatient.
.
RHYTHM: The patient was monitored on telemetry and daily EKGs
were performed during her CCU stay. She had slight QT
prolongation which resolved and her nonspecific ST changes also
improved during her hospital course. She was in normal sinus
rhythm at time of discharge.
.
RIGHT GROIN HEMATOMA /ARTERIAL BLEED: As a complication of her
cardiac catheterization the patient suffered a groin hematoma
after an accidental arterial bleed. The inferior epigastric
artery was emergently ligated and a hematoma (approximately
500cc)was evacuated by the vascular surgery team. She had an
initial Hct drop from 34 to 20 which stabilized after 4 Units of
blood and over 6 liters of IVF resuscitation. The patient's Hct
levels were checked q6hrs post-surgery and then twice daily as
her Hct stabilized. At time of discharge her Hct was 29.6 and
she had no residual right groin pain and minimal discomfort with
walking. PT cleared the patient to return home and she was
cautioned to avoid lifting heavy objects 9>10lbs) until her
incision site had healed completely in [**4-26**] weeks. She will plan
to follow up in 2 weeks at the vascular clinic to have her
staples removed.
.
THROMBOCYTOPENIA: Post-operatively the patient had some lasting
thombocytopenia with platelets in the 70-80s range at the nadir.
This was most likely consumption related given her large bleed
with abundant clotting. DIC workup was unrevealing and given the
timeline HIT was felt to be a less likely culprit. Mrs. [**Known lastname 75809**] platelets were trended and fortunately began to rise
into the 90s and she was at 133 platelets by time of discharge.
She had no additional bruising, petechiae, hypotension or
further complications.
.
LEUKOCYTOSIS: The patient had a spike to a white blood cell
count of 17.9 with neutrophilia but no left shift. on [**2139-11-6**]
which soon tapered down to within normal range over the next 48
hours. She had no febrile patterns, UA and urine cultures were
negative and her CXR had no consolidations. IV sites and
surgical staples were in tact,clean,non-erythematous  and
without any signs of discharge. The brief leukocytosis was
likely related to stress response of bleeding.
.
HYPERTENSION: Initially, the patient's blood pressures were in
the hypotensive range and all blood pressure medications were
held. As she stabilized by hospital day [**3-24**] she was gradually
restarted on low dose Lisinopril and Toprol XL was added given
her low EF and cardiomyopathy.
.
GLAUCOMA : While an inpatient in the CCU the patient was
continued on her usual eye drops that she takes for her
Glaucoma. She will plan to follow-up as an outpatient with her
opthalmologist regarding the need to post-[**Last Name (un) 9495**] her scheduled
surgery a few weeks until she recovers from a recent acute bleed
and until she recuperates from her current cardiomyopathy.
.
PROPHYLAXIS / CODE STATUS : Anticoagulation was held in the
setting of a new acute bleed. Pneumoboots were used for DVT
prophylaxis and physical therapy was called by hospital day two
to help the patient ambulate better. She was given Protonix for
GI  prophylaxis in the setting of her intubation and she was
given a bowel
regimen of Senna and Colace to maintain regularity. Mrs. [**Known lastname 75808**]

was maintained as a full code status for the entirety of her
hospital stay.
.
Upon discharge, she was set up for a repeat echo in a few weeks
and follow-up appointments with Dr. [**Last Name (STitle) **] and the vascular
surgery clinic.  She was asked to please return to the emergency
room or call her new cardiologist or PCP as soon as possible if
she had any worsening shortness of breath, chest pain,
dizziness,lightheadedness or signs of bleeding, discharge or
erythema at her incision site in her right groin.


Medications on Admission:
Home Medications:
Dorzolamide-Timolol 2-0.5 % eye drops tid
Travatan 0.004 % eye drops qhs
Lisinopril 5mg daily
Occasional OTC Tylenol
.
Medications on Admission:
Heparin drip and Integrilin started [**11-4**] but discontinued in
setting of acute bleed on [**11-5**] (off both at CCU transfer time)
-plavix 600mg [**11-4**], 75mg [**11-5**]
-lopressor 25mg po .
-lipitor 40mg
-nitro paste 1 inch q 4 hours
-cosopt eye gtts
.

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
5. TRAVATAN Z 0.004 % Drops Sig: One (1) gtt both eyes
Ophthalmic HS (at bedtime).
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Takotsubo Syndrome / Cardiomyopathy
Right groin bleed requiring surgical repair
Thrombocytopenia
Glaucoma


Discharge Condition:
Stable
Hct=29.6
Creat=0.7
K=4.1
BUN: 19


Discharge Instructions:
You had a cardiac catheterization and that showed a weakness in
your heart that is consistant with Takotsubo syndrome. This
syndrome is similar to a heart attack but your coronary arteries
do not show any major blockages. You have been continued on your
previous medicines except your Lisinopril was decreased to 5 mg
daily. Your new medicine is Toprol XL ( a beta blocker) that
helps your heart pump better. You will need to have an ECHO in 3
weeks that will evaluate the function of your heart. After your
catheterization, you had a large blood collection in your right
groin that required surgical repair. This is now stable but an
appt to take out the staples has been scheduled for you.
.
Your heart fucntion is somewhat weak, we expect this will
improve over the next few months. Please weigh yourself every
day and tell Dr. [**Last Name (STitle) **] if you develop a weight gain more than
3 pounds in 1 day or 6 pounds in 3 days. Please also call Dr.
[**Last Name (STitle) **] if you see that you have sweeling in your legs and feet
or if you have difficulty breathing.
Call Dr. [**Last Name (STitle) 172**] or Dr. [**Last Name (STitle) **] if you notice increased
swelling, pain or redness in your right groin. Also call for
chest pain, nausea, sweating or fevers.


Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2037**] from Cardiology, [**12-2**]
at 1 p.m. in [**Hospital Ward Name 23**] 7th on the [**Hospital Ward Name 516**] at the [**Hospital3 **].

You have to come in on [**11-30**] at 3 p.m. for an
echocardiogram which is an ultrasound of your heart, this is
also on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] Phone: [**Telephone/Fax (1) 133**] Date/time: Tuesday [**11-17**] at 3:00 pm.
.
[**Hospital **] Clinic: for staple removal Dr. [**Last Name (STitle) **] Phone: ([**Telephone/Fax (1) 1804**] Date/time: [**11-25**] at 12:00 pm. [**Hospital Unit Name **]
[**Hospital Unit Name **], [**Last Name (NamePattern1) 439**].



Completed by:[**2139-11-10**]
{'Takotsubo syndrome,Cardiogenic shock,Hematoma complicating a procedure,Acute combined systolic and diastolic heart failure,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Other iatrogenic hypotension,Unspecified glaucoma,Osteoporosis, unspecified,Unspecified essential hypertension'}


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



### Clinical text :
CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: The patient is a 76-year-old female transferred from the [**First Name4 (NamePattern1) 3075**]
[**Last Name (NamePattern1) 3549**] Hospital ER on the evening of [**2139-11-4**] with chest pain
radiating to her right posterior shoulder area. Initial EKG had
some non-specific ST changes concerning for NSTEMI and EF per
ECHO (TTE) done at OSH noted to be 15%.  Per outside hospital
records the patient had reported that her pain was relieved
after SL nitroglycerin tablets x 3 and Lopressor 5mg IV x 3. She
was also given a loading dose of Plavix 600mg in the ER and 75mg
the following morning and she was started on both Integrillin
and Heparin and was transferred directly to the cardiac
catheterization lab at [**Hospital1 18**] and found to not have any
obstructive coronary disease, LV-gram showing EF closer to 30%
but prominent apical ballooning consistent with Takotsubo's
Cardiomyopathy presentation. She began to have severe
hypotension during her cardiac catheterization and was started
on Dopamine then switched to Neosynephrine. She was noted to
have an expanding right groin. Of note, given reported
difficulty obtaining access initially thought was that she was
having a iatrogenic bleed.
.
In the operating room the patient was continued on
Neosynephrine, and had a right internal jugular central venous
line placed and failed attempt at a radial arterial line.
Intubation was uncomplicated. The patient was also given a total
of 3.5L of NS and 2 Units blood were given. Just prior to going
to the operating room with the vascular surgery team the patient
was also given IVFs and 2 Units of blood in cardiac
catheterization lab. Thus, she received in total, 4 Units of
blood before transfer up to CCU post-operatively. She was able
to be slowly weaned off of Neosynephrine and BP was 115/70 upon
presentation to the CCU. Per vascular team, the inferior
epigastric artery on the right was ligated and a hematoma was
evacuated, removing roughly 500cc of blood. Pressure dressing
was applied. Patient arrived to the CCU intubated and sedated
and a few continued bouts of intermittent low blood pressures.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: negative for Diabetes, no significant
dyslipidemia, but positive for age, hypertension, sedentary
lifestyle
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None / No priors
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Glaucoma
Osteoporosis
Cataracts

MEDICATION ON ADMISSION: Home Medications:
Dorzolamide-Timolol 2-0.5 % eye drops tid
Travatan 0.004 % eye drops qhs
Lisinopril 5mg daily
Occasional OTC Tylenol
.
Medications on Admission:
Heparin drip and Integrilin started [**11-4**] but discontinued in
setting of acute bleed on [**11-5**] (off both at CCU transfer time)
-plavix 600mg [**11-4**], 75mg [**11-5**]
-lopressor 25mg po .
-lipitor 40mg
-nitro paste 1 inch q 4 hours
-cosopt eye gtts
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: No known family history of significant CAD, premature coronary
artery disease or sudden death.

SOCIAL HISTORY: The patient is married and lives in [**Location 1110**] with her husband. She
has one daughter who lives locally. In terms of recent stressors
the patient reports some anxiety regarding an upcoming Glaucoma
surgery and some additional stress and residual grief as she
learned that her brother died several months ago. 

### Response:
{'Takotsubo syndrome,Cardiogenic shock,Hematoma complicating a procedure,Acute combined systolic and diastolic heart failure,Accidental cut, puncture, perforation or hemorrhage during heart catheterization,Other iatrogenic hypotension,Unspecified glaucoma,Osteoporosis, unspecified,Unspecified essential hypertension'}
