CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 56M ESRD on HD HTN DM HL s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA
to LAD double touchdown with endarterectomy from D1 to apex;
SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good resolution of
symptoms, follow up stress echo in [**Month (only) 359**] showing small apical
scar with some peri-apical ischemia and a preserved EF (50%)
felt [**3-17**] diffusely diseased LAD) who presents s/p VF arrest. He
reports that about 2-4 weeks ago he began to note chest
discomfort which he thought was just gas since it often occurred
with burping. The pain was dull, center of chest, did not
radiate to arm or jaw, no associated shortness of breath,
nausea, vomiting or diaphoresis. The episodes lasted minutes,
resolved on their own, occured a few times a week, not
associated with exercise. Since he thought it was GI related he
did not seek further attention.
.
Last night he had worsening of discomfort which continued on
through most of the night. This morning started to go to his
routine HD appointment but 1 block from home felt poorly with
midsternal nonradiating chest pressure. He went home and asked
his wife to call 911. In the ambulance on the way over he went
into a VF arrest and was promptly resucitated. He had not taken
his morning metoprolol.
.
He was taken to [**Hospital6 33**] where on arrival his EKG at
[**Hospital6 33**] showed new downsloping in leads aVF II III
V3-V6
His pain went away with nitroglycerin. He was started on heparin
and integrilin and sent to [**Hospital1 18**] for cardiac catheterization.
.
His cardiac cath (Attending: Dr. [**Last Name (STitle) 33746**] showed patent grafts to
the PDA and LIMA to LAD but an occluded graft to OM1. Flow to
territority through native circumflex. Given tight left main
stenosis as well as 80% proximal left circumflex stenosis two
long drug eluting stents (a Promus 3.5mm x 23 mm and a Promus
3.5mm x 18mm) were placed in the left main and left circumflex
respectively. Entry sites were closed with an 8F RFA AngioSeal
in right groin and 5F RFA sheath pull in left. Of note his blood
pressure dropped to systolics in the 60s during both baloon
inflations. He otherwise tolerated the procedure without any
complications.
.
Prior to the catheterization his potassium was 6.1. No EKG
changes of hyperkalemia. Received 10 units of insulin, D50 and
2gm of calcium gluconate. Post-cath K+ same at 6.1. Also
received some D5W for blood sugars in the 80s. He reports having
taken his NPH the morning of admissions.
.
On arrival to the CCU he was comfortable and in NAD. All of his
prior symptoms had resolved and he had no current complaints.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
Tobacco use
2. CARDIAC HISTORY:
- CABG: [**2155-12-9**] CABG x 5, PTCA to 6th.
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2156-9-3**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Diabetes mellitus with renal complications, and neuropathy,
-retinopathy. Most recent Hg A1c in [**Month (only) 116**] was 7.3 from previous <
7.0.
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
-Hypertension, Essential
-Cataract
-Charcot foot due to diabetes mellitus
-History of tobacco use
-Hypothyroidism
-Hyperlipidemia
-Obesity s/p Lap Band ([**2154**])
-Hyperparathyroidism [**3-17**] renal
-Renal osteodystrophy
-Pulmonary Nodule (Solitary)
-History of Colonic Adenoma

MEDICATION ON ADMISSION: 1. FoLIC Acid 1 mg PO/NG DAILY
2. Heparin 5000 UNIT SC TID
3. Insulin SC (per Insulin Flowsheet)
4. Aspirin EC 325 mg PO DAILY
5. Levothyroxine Sodium 300 mcg PO/NG DAILY
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
7. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **]
8. Atorvastatin 80 mg PO/NG DAILY
9. Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
10. Clopidogrel 75 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Clopidogrel 300 mg PO/NG ONCE
13. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Docusate Sodium 100 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: 97.9 93/45 (69-98) 65 19 99%RA
Wt 105.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema
Access: left forearm AVF + thrill/bruit

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

SOCIAL HISTORY: - Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
- ETOH: never
- Illicit drugs: denies
Subendocardial infarction, initial episode of care,End stage renal disease,Ventricular fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of autologous vein bypass graft,Hyperpotassemia,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Obstructive sleep apnea (adult)(pediatric),Other diseases of lung, not elsewhere classified,Other and unspecified hyperlipidemia,Other cataract,Renal dialysis status,Long-term (current) use of insulin,Personal history of tobacco use
Subendo infarct, initial,End stage renal disease,Ventricular fibrillation,Hyp kid NOS w cr kid V,Crn ath atlg vn bps grft,Hyperpotassemia,Neuropathy in diabetes,Arthropathy w nerve dis,DMII neuro nt st uncntrl,Obesity NOS,Diabetic retinopathy NOS,Hypothyroidism NOS,Obstructive sleep apnea,Other lung disease NEC,Hyperlipidemia NEC/NOS,Cataract NEC,Renal dialysis status,Long-term use of insulin,History of tobacco use
Admission Date:  [**2156-9-3**]              Discharge Date:   [**2156-9-6**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Name (NI) 9308**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
PCI
Hemodialysis


History of Present Illness:
56M ESRD on HD HTN DM HL s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA
to LAD double touchdown with endarterectomy from D1 to apex;
SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good resolution of
symptoms, follow up stress echo in [**Month (only) 359**] showing small apical
scar with some peri-apical ischemia and a preserved EF (50%)
felt [**3-17**] diffusely diseased LAD) who presents s/p VF arrest. He
reports that about 2-4 weeks ago he began to note chest
discomfort which he thought was just gas since it often occurred
with burping. The pain was dull, center of chest, did not
radiate to arm or jaw, no associated shortness of breath,
nausea, vomiting or diaphoresis. The episodes lasted minutes,
resolved on their own, occured a few times a week, not
associated with exercise. Since he thought it was GI related he
did not seek further attention.
.
Last night he had worsening of discomfort which continued on
through most of the night. This morning started to go to his
routine HD appointment but 1 block from home felt poorly with
midsternal nonradiating chest pressure. He went home and asked
his wife to call 911. In the ambulance on the way over he went
into a VF arrest and was promptly resucitated. He had not taken
his morning metoprolol.
.
He was taken to [**Hospital6 33**] where on arrival his EKG at
[**Hospital6 33**] showed new downsloping in leads aVF II III
V3-V6
His pain went away with nitroglycerin. He was started on heparin
and integrilin and sent to [**Hospital1 18**] for cardiac catheterization.
.
His cardiac cath (Attending: Dr. [**Last Name (STitle) 33746**] showed patent grafts to
the PDA and LIMA to LAD but an occluded graft to OM1. Flow to
territority through native circumflex. Given tight left main
stenosis as well as 80% proximal left circumflex stenosis two
long drug eluting stents (a Promus 3.5mm x 23 mm and a Promus
3.5mm x 18mm) were placed in the left main and left circumflex
respectively. Entry sites were closed with an 8F RFA AngioSeal
in right groin and 5F RFA sheath pull in left. Of note his blood
pressure dropped to systolics in the 60s during both baloon
inflations. He otherwise tolerated the procedure without any
complications.
.
Prior to the catheterization his potassium was 6.1. No EKG
changes of hyperkalemia. Received 10 units of insulin, D50 and
2gm of calcium gluconate. Post-cath K+ same at 6.1. Also
received some D5W for blood sugars in the 80s. He reports having
taken his NPH the morning of admissions.
.
On arrival to the CCU he was comfortable and in NAD. All of his
prior symptoms had resolved and he had no current complaints.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
Tobacco use
2. CARDIAC HISTORY:
- CABG: [**2155-12-9**] CABG x 5, PTCA to 6th.
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2156-9-3**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Diabetes mellitus with renal complications, and neuropathy,
-retinopathy. Most recent Hg A1c in [**Month (only) 116**] was 7.3 from previous <
7.0.
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
-Hypertension, Essential
-Cataract
-Charcot foot due to diabetes mellitus
-History of tobacco use
-Hypothyroidism
-Hyperlipidemia
-Obesity s/p Lap Band ([**2154**])
-Hyperparathyroidism [**3-17**] renal
-Renal osteodystrophy
-Pulmonary Nodule (Solitary)
-History of Colonic Adenoma

Social History:
- Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
- ETOH: never
- Illicit drugs: denies

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

Physical Exam:
ADMISSION EXAM
Vitals: 97.9 93/45 (69-98) 65 19 99%RA
Wt 105.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema
Access: left forearm AVF + thrill/bruit

DISCHARGE EXAM
Vitals: 97.7, 89, 106/61, 19, 99% on RA
GEN: AOX3, NAD
HEENT: anicteric sclera, MMM, PERRL
NECK: JVP not elevated
HEART: RRR, grade 2 systolic murmur heard best at LSB/2ICS, no
radiation to neck or axilla
LUNG: CTA bilaterally
ABD: soft, NT/ND, +BS, no hepatosplenomegaly
EXT: nonpitting edema to ankle bilaterally, peripheral pulse 2+
in LE bilaterally, fistula with thrills over left forearm

Pertinent Results:
ADMISSION LABS
[**2156-9-3**] 02:45PM BLOOD WBC-8.2 RBC-3.47* Hgb-11.4* Hct-32.6*
MCV-94 MCH-32.8* MCHC-35.0 RDW-15.1 Plt Ct-170
[**2156-9-3**] 02:45PM BLOOD Neuts-66.6 Lymphs-23.5 Monos-5.0 Eos-3.7
Baso-1.2
[**2156-9-3**] 10:23PM BLOOD PT-12.4 PTT-26.2 INR(PT)-1.0
[**2156-9-3**] 08:50AM BLOOD Glucose-159* UreaN-51* Creat-8.8* Na-139
K-6.1* Cl-95* HCO3-28 AnGap-22*
[**2156-9-3**] 10:23PM BLOOD ALT-39 AST-69* CK(CPK)-321 AlkPhos-94
TotBili-0.6
[**2156-9-3**] 08:50AM BLOOD Calcium-9.9 Phos-4.6* Mg-3.2*

PERTINENT LABS
[**2156-9-3**] 08:50AM BLOOD CK-MB-20* MB Indx-9.8* cTropnT-0.59*
[**2156-9-3**] 10:23PM BLOOD CK-MB-35* MB Indx-10.9* cTropnT-2.49*
[**2156-9-4**] 04:32AM BLOOD CK-MB-22* MB Indx-10.3*
[**2156-9-4**] 04:50PM BLOOD CK-MB-12* MB Indx-5.8 cTropnT-2.35*

DISCHARGE LABS
[**2156-9-6**] 06:32AM BLOOD WBC-5.6 RBC-2.72* Hgb-9.1* Hct-25.4*
MCV-93 MCH-33.5* MCHC-35.9* RDW-14.6 Plt Ct-130*
[**2156-9-6**] 06:32AM BLOOD Glucose-105* UreaN-63* Creat-10.3*#
Na-135 K-6.2* Cl-94* HCO3-28 AnGap-19
[**2156-9-6**] 06:32AM BLOOD Calcium-8.2* Phos-6.0* Mg-2.8*

PERTINENT STUDIES
# [**9-4**] ECHO
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with mild
hypokinesis of the inferolateral wall and basal inferior
segment. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with borderline-normal free
wall contractility. 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. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.

IMPRESSION: Mild focal left ventricular systolic dysfunction.
Mildly dilated right ventricle with borderline normal systolic
function. No significant valvular abnormality seen.

# [**9-3**] cardiac catheterization
1. Severe left main and 3 vessel native CAD. 4 patent grafts out
of 5.
2. Successful PTCA/stenting of left main and LCx using DES


Brief Hospital Course:
56M ESRD on HD, HTN, DM, HL s/p CABG [**5-/2155**] (3vd, 5-CABG with
LIMA to LAD double touchdown with endarterectomy from D1 to
apex; SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good
resolution of symptoms, follow up stress echo in [**Month (only) 359**] showing
small apical scar with some peri-apical ischemia and a preserved
EF (50%) felt [**3-17**] diffusely diseased LAD) who presents NSTEMI
s/p VF arrest and underwent stenting in LCA and LCx.

ACTIVE ISSUES:
1. CAD s/p VF Arrest: Patient is s/p 5-CABG in [**2155**]. Cardiac
cath this admission showed severe left main and 3v native CAD
with 4 out of 5 grafts patent. Had 2x DES placed in left main
and left circumflex. Continued on aspirin and plavix. Integrilin
stopped in cath lab. Repeat echo showed no change in LVEF.

2. CHF: Patient with ESRD but normal EF ~50% on prior echo.
Initial CXR and exam c/w fluid overload which improved with HD.
He had a repeat echo which showed no change in his EF. No
indications for ICD. Should continue to weigh self regularly and
follow a low salt diet.

3. ESRD: Dialyzed immediately post cath and then again on day of
discharge. Removed 1.5L post cath but HD session was not
completed due to asymptomatic hypotension with MAPs down to 42.
Tolerated additional HD on hospital day #3 (day of discharge)
and removed ~4L. Had ongoing asymptomatic hypotension which was
felt consistent with the patient's baseline during HD. Will have
next HD at his regular time on Wednesday.

4. Hyperkalemia: K 6.1 on admission, no hyperkalemic EKG
changes, given insulin and D5 and calc gluc. Resolved with HD.
K+ 6.2 on morning of discharge prior to HD. Felt appropriate to
recheck labs at follow up appointment or next HD session on
wednesday.

5. DM, Type II: long-standing diabetic now managed on insulin.
Most recent A1c ~7.5, notes slightly worse control recently as
he has been less careful with what he eats. Managed on HISS
inhouse, restarted home regimen of Aspart/NPH on discharge.

6. HLD: Previously on simvastatin 40mg daily which was switched
to atorvastatin 80mg in the setting of an acute MI.

CHRONIC ISSUES
Pt has documented history of hypothyroidism.  Home dose
levothyroxine was continued.

TRANSITIONAL ISSUES
Pt maintained a full code.
Pt has a followup appointment with Dr. [**Last Name (STitle) 66687**] on Tuesday ([**9-7**]).


Medications on Admission:
1. FoLIC Acid 1 mg PO/NG DAILY
2. Heparin 5000 UNIT SC TID
3. Insulin SC (per Insulin Flowsheet)
4. Aspirin EC 325 mg PO DAILY
5. Levothyroxine Sodium 300 mcg PO/NG DAILY
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
7. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **]
8. Atorvastatin 80 mg PO/NG DAILY
9. Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
10. Clopidogrel 75 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Clopidogrel 300 mg PO/NG ONCE
13. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Docusate Sodium 100 mg PO BID


Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 100 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. sevelamer carbonate 2.4 gram Powder in Packet Sig: Two (2)
envelopes PO three times a day.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. insulin aspart 100 unit/mL Solution Sig: 0-20 units per
sliding scale units Subcutaneous three times a day.
9. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
10-20 units daily as directed units Subcutaneous once a day.
10. mupirocin 2 % Ointment Topical
11. epoetin alfa 2,000 unit/mL Solution Sig: 3.5 ml Injection
three times a week with dialysis for 1 doses.
12. paricalcitol 2 mcg/mL Solution Sig: Two (2) ml Intravenous
three times a week with dialysis.
13. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day:
Please hold morning dose on the day of dialysis.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
1. non ST elevation myocardial infartion
2. congestive heart failure

SECONDARY:
1. chronic kidney disease


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


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

You were sent to our hospital by ambulance and was found to have
a heart attack.  You had a dangerous heart rhythm on the
ambulance en route to our hospital, and was successfully
corrected in time.  After arrival, you underwent catheterization
of your heart.  Two stents were placed to open up your occluded
coronary vessels.  You also had a hemodialysis on the day of
your discharge, which you tolerated well.  You recovered well
from your heart attack.  We think you are now safe to go home
and continue recovery.

Please note that the following medications have been changed:
- Please STOP taking simvastatin
- Please START taking atorvastatin 80 mg by mouth daily

You have a followup appointment with your new cardiologist Dr.
[**Last Name (STitle) 66687**] at [**Hospital1 392**] center at 4 pm on Tuesday ([**9-7**]).

Please also be sure to have your labs checked either at your
cardiology appointment on Tuesday ([**9-7**]) or Wednesday ([**9-8**]) at
dialysis.

It has been a pleasure to take care of you here at [**Hospital1 18**].  We
hope you have a speedy recovery.

Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66687**], [**First Name3 (LF) **], Cardiology
[**Hospital1 **], [**First Name4 (NamePattern1) 392**] [**Last Name (NamePattern1) **]
TIME: Tuesday ([**9-7**]) at 4 pm
LOCATION: [**Location (un) **], [**Hospital1 392**], [**Numeric Identifier 10727**]
CONTACT: ([**Telephone/Fax (1) 90366**]
{'Subendocardial infarction, initial episode of care,End stage renal disease,Ventricular fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of autologous vein bypass graft,Hyperpotassemia,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Obstructive sleep apnea (adult)(pediatric),Other diseases of lung, not elsewhere classified,Other and unspecified hyperlipidemia,Other cataract,Renal dialysis status,Long-term (current) use of insulin,Personal history of tobacco use'}


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: 56M ESRD on HD HTN DM HL s/p CABG [**5-/2155**] (3vd, 5-CABG with LIMA
to LAD double touchdown with endarterectomy from D1 to apex;
SVG1 to OM1 and jump to OM2; and SVG2 to PDA; good resolution of
symptoms, follow up stress echo in [**Month (only) 359**] showing small apical
scar with some peri-apical ischemia and a preserved EF (50%)
felt [**3-17**] diffusely diseased LAD) who presents s/p VF arrest. He
reports that about 2-4 weeks ago he began to note chest
discomfort which he thought was just gas since it often occurred
with burping. The pain was dull, center of chest, did not
radiate to arm or jaw, no associated shortness of breath,
nausea, vomiting or diaphoresis. The episodes lasted minutes,
resolved on their own, occured a few times a week, not
associated with exercise. Since he thought it was GI related he
did not seek further attention.
.
Last night he had worsening of discomfort which continued on
through most of the night. This morning started to go to his
routine HD appointment but 1 block from home felt poorly with
midsternal nonradiating chest pressure. He went home and asked
his wife to call 911. In the ambulance on the way over he went
into a VF arrest and was promptly resucitated. He had not taken
his morning metoprolol.
.
He was taken to [**Hospital6 33**] where on arrival his EKG at
[**Hospital6 33**] showed new downsloping in leads aVF II III
V3-V6
His pain went away with nitroglycerin. He was started on heparin
and integrilin and sent to [**Hospital1 18**] for cardiac catheterization.
.
His cardiac cath (Attending: Dr. [**Last Name (STitle) 33746**] showed patent grafts to
the PDA and LIMA to LAD but an occluded graft to OM1. Flow to
territority through native circumflex. Given tight left main
stenosis as well as 80% proximal left circumflex stenosis two
long drug eluting stents (a Promus 3.5mm x 23 mm and a Promus
3.5mm x 18mm) were placed in the left main and left circumflex
respectively. Entry sites were closed with an 8F RFA AngioSeal
in right groin and 5F RFA sheath pull in left. Of note his blood
pressure dropped to systolics in the 60s during both baloon
inflations. He otherwise tolerated the procedure without any
complications.
.
Prior to the catheterization his potassium was 6.1. No EKG
changes of hyperkalemia. Received 10 units of insulin, D50 and
2gm of calcium gluconate. Post-cath K+ same at 6.1. Also
received some D5W for blood sugars in the 80s. He reports having
taken his NPH the morning of admissions.
.
On arrival to the CCU he was comfortable and in NAD. All of his
prior symptoms had resolved and he had no current complaints.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension,
Tobacco use
2. CARDIAC HISTORY:
- CABG: [**2155-12-9**] CABG x 5, PTCA to 6th.
- PERCUTANEOUS CORONARY INTERVENTIONS: [**2156-9-3**]
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Diabetes mellitus with renal complications, and neuropathy,
-retinopathy. Most recent Hg A1c in [**Month (only) 116**] was 7.3 from previous <
7.0.
-Obstructive Sleep Apnea (previously on CPAP, now resolved after
weight loss)
-Hypertension, Essential
-Cataract
-Charcot foot due to diabetes mellitus
-History of tobacco use
-Hypothyroidism
-Hyperlipidemia
-Obesity s/p Lap Band ([**2154**])
-Hyperparathyroidism [**3-17**] renal
-Renal osteodystrophy
-Pulmonary Nodule (Solitary)
-History of Colonic Adenoma

MEDICATION ON ADMISSION: 1. FoLIC Acid 1 mg PO/NG DAILY
2. Heparin 5000 UNIT SC TID
3. Insulin SC (per Insulin Flowsheet)
4. Aspirin EC 325 mg PO DAILY
5. Levothyroxine Sodium 300 mcg PO/NG DAILY
6. Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
7. Mupirocin Cream 2% 1 Appl TP [**Hospital1 **]
8. Atorvastatin 80 mg PO/NG DAILY
9. Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
10. Clopidogrel 75 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Clopidogrel 300 mg PO/NG ONCE
13. Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Docusate Sodium 100 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: 97.9 93/45 (69-98) 65 19 99%RA
Wt 105.5 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema
Access: left forearm AVF + thrill/bruit

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

SOCIAL HISTORY: - Tobacco history: 30 pack year history, quit at time of CABG ~1
year ago
- ETOH: never
- Illicit drugs: denies 

### Response:
{'Subendocardial infarction, initial episode of care,End stage renal disease,Ventricular fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of autologous vein bypass graft,Hyperpotassemia,Polyneuropathy in diabetes,Arthropathy associated with neurological disorders,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Background diabetic retinopathy,Unspecified acquired hypothyroidism,Obstructive sleep apnea (adult)(pediatric),Other diseases of lung, not elsewhere classified,Other and unspecified hyperlipidemia,Other cataract,Renal dialysis status,Long-term (current) use of insulin,Personal history of tobacco use'}
