CHIEF COMPLAINT: DATE: [**2116-3-21**]
.
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) **],[**First Name3 (LF) **]
.
Chief Complaint: SSCP

PRESENT ILLNESS: HISTORY OF PRESENTING ILLNESS:
.
Patient is a 73 y/o F w/ a hx of CAD, s/p DES to OM1, [**7-29**], CHF
no echo on file, Paroxysmal Afib, not on anticoagulation, Severe
Pulmonary HTN on Viagra 20mg TID, hx of COPD home oxygen of 4L,
PVD, PUD, who presents on [**3-20**] to [**Hospital 487**] hospital with
Nausea/Vomiting, Abdominal Pain, Acute on Chronic renal failure
w/ Cr of 2.1, found to have BP in [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] of 196/99, dig
level of 4.6, w/ 5mg IV morphine, 2.5mg IV lopressor w/
improvement of BP to 140/60 and HR in 90s. Nausea and vomiting
had been going on for 3 days prior to presentation.
.
Patient's N/V and Renal failure were thought to be secondary to
dig toxicity. An abdominal non-contrast CT scan was done which
showed no acute finding, atrophic R kidney, and sigmoid
diverticula. They suspected patients findings were secondary to
dig toxicity.
.
At 4am on [**3-21**] patient developed Severe [**10-2**] SSCP w/ radiation
to her back the pain continued for 30minutes. Patient was noted
to have ECG findings significant for 3mm ST depression in leads
v3-v6, 2mm ST elevation in AVR, 2-3mm downward sloping ST
depressions in leads 2, 3, avf. Patient was noted to have BP
183/88 in L arm and 155/97 in L arm.
.
Patient was transferred to [**Hospital1 18**] for work up of a possible
aortic dissection.

MEDICAL HISTORY: Percutaneous coronary intervention, in [**7-29**] anatomy as follows:

MEDICATION ON ADMISSION: CURRENT MEDICATIONS:
MEDICATIONS
Advair 250/50 1puff [**Hospital1 **]
Spiriva 1mg daily
Nexium 40mg daily
Nitro-[**Hospital1 **] 6.5mg TID
Lipitor 40mg qhs
Lasix 20mg PO prn
Lopressor 25mg PO BID
ASA EC 325mg daily
[**Last Name (un) **]-dur 200mg PO BID
Cardizem 30mg PO TID
Prednisone 10mg daily
Plavix 75mg daily
Citracal unknown daily
Potassium 10mg daily
viagra 20mg TID
Cozaar ? PO daily
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - T 96.9, HR 90, BP L arm 170/90, R arm 160/80
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient quit smoking 10 years ago. She started at age 12 for a
greater than 50 pack year history. No etoh or illicit drugs.
Lives at home with husband. [**Name (NI) **] to complete daily ADLs.
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other chronic pulmonary heart diseases,Chronic kidney disease, unspecified,Hypoxemia,Other iatrogenic hypotension,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Peripheral vascular disease, unspecified,Aortic valve disorders,Esophageal reflux,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Subendo infarct, initial,Acute kidney failure NOS,Ac on chr diast hrt fail,Crnry athrscl natve vssl,Atrial fibrillation,Chr pulmon heart dis NEC,Chronic kidney dis NOS,Hypoxemia,Iatrogenc hypotnsion NEC,Adv eff cardiotonics,Hy kid NOS w cr kid I-IV,Postinflam pulm fibrosis,Periph vascular dis NOS,Aortic valve disorder,Esophageal reflux,Depend-supplement oxygen,History of tobacco use,Abn react-cardiac cath
Admission Date:  [**2116-3-21**]              Discharge Date:   [**2116-4-1**]

Date of Birth:  [**2042-10-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
DATE: [**2116-3-21**]
.
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) **],[**First Name3 (LF) **]
.
Chief Complaint: SSCP


Major Surgical or Invasive Procedure:
Cardiac Cath

History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
.
Patient is a 73 y/o F w/ a hx of CAD, s/p DES to OM1, [**7-29**], CHF
no echo on file, Paroxysmal Afib, not on anticoagulation, Severe
Pulmonary HTN on Viagra 20mg TID, hx of COPD home oxygen of 4L,
PVD, PUD, who presents on [**3-20**] to [**Hospital 487**] hospital with
Nausea/Vomiting, Abdominal Pain, Acute on Chronic renal failure
w/ Cr of 2.1, found to have BP in [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] of 196/99, dig
level of 4.6, w/ 5mg IV morphine, 2.5mg IV lopressor w/
improvement of BP to 140/60 and HR in 90s. Nausea and vomiting
had been going on for 3 days prior to presentation.
.
Patient's N/V and Renal failure were thought to be secondary to
dig toxicity. An abdominal non-contrast CT scan was done which
showed no acute finding, atrophic R kidney, and sigmoid
diverticula. They suspected patients findings were secondary to
dig toxicity.
.
At 4am on [**3-21**] patient developed Severe [**10-2**] SSCP w/ radiation
to her back the pain continued for 30minutes. Patient was noted
to have ECG findings significant for 3mm ST depression in leads
v3-v6, 2mm ST elevation in AVR, 2-3mm downward sloping ST
depressions in leads 2, 3, avf. Patient was noted to have BP
183/88 in L arm and 155/97 in L arm.
.
Patient was transferred to [**Hospital1 18**] for work up of a possible
aortic dissection.


Past Medical History:
Percutaneous coronary intervention, in [**7-29**] anatomy as follows:

.
COMMENTS:
1. Coronary angiography of this right dominant system
demonstrated
single vessel coronary artery disease. The LMCA had a 30% distal

stenosis. The LAD had diffuse irregularities. The LCx had 70%
disease
in the mid-OM1. There was a 70% ostial stenosis of a small AV
branch.
The RCA had diffuse irregularities.
2. Limited resting hemodynamics revealed normal systemic
arterial
hypertension (125/57 mm Hg).
3. Successful PTCA and stenting of a 70% OM1 lesion was
performed with
a 2.5x23 mm Cypher stent. Final angiography revealed 0% residual

stenosis, no dissection, and TIMI 3 flow. (See PTCA comments)
.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Successful PTCA and drug-eluting stenting of OM1
.
Other Past History:
PMHX:
PVD
CAD w/ known stents
Oxygen dependent w/ chronic dyspnea, 4L home o2.
Pulmonary HTN, came in on viagra
Afib
COPD
Past GI bleeds
CHF
Prior left carotid endarerectomy


Social History:
Patient quit smoking 10 years ago. She started at age 12 for a
greater than 50 pack year history. No etoh or illicit drugs.
Lives at home with husband. [**Name (NI) **] to complete daily ADLs.

Family History:
NC

Physical Exam:
PHYSICAL EXAMINATION:
VS - T 96.9, HR 90, BP L arm 170/90, R arm 160/80
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

Neck: Supple with JVP of 14 cm at 90 degree
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No thrills, lifts. No
S3 or S4.
Chest: Crackles bilaterally, [**12-25**] way up posteriorly.
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace edema lower ext, weak dp/pt bilaterally
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+


Pertinent Results:
OSH LABS
sodium 138=>133
K 4.7
Cl 99
bicarb 26
BUN 27=>37
Cr1.5=>2.1
Glucose 180-210
.
BNP 3395
.
Normal LFTs
.
Lipase 37
.
Dig level 4.7
.
WBC 11.78=>10.5
Hct 32.6
Plt 248
.
CK 60
Trop 0.06=>0.10
.
ABG=7.47/35/72/
ADMISSION LABS:
.
[**2116-3-21**] 09:30AM BLOOD WBC-8.9 RBC-4.53 Hgb-12.5 Hct-37.8 MCV-83
MCH-27.6 MCHC-33.0 RDW-16.2* Plt Ct-251
[**2116-3-21**] 09:30AM BLOOD Neuts-91.6* Bands-0 Lymphs-6.5*
Monos-1.7* Eos-0.1 Baso-0.1
[**2116-3-21**] 09:30AM BLOOD PT-11.8 PTT-23.5 INR(PT)-1.0
[**2116-3-21**] 09:30AM BLOOD Glucose-197* UreaN-34* Creat-1.6* Na-130*
K-4.7 Cl-92* HCO3-25 AnGap-18
[**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264*
AlkPhos-56 Amylase-65 TotBili-0.6
[**2116-3-21**] 09:30AM BLOOD Albumin-3.9 Calcium-8.8 Phos-4.2 Mg-1.5*
Cholest-156
[**2116-3-21**] 09:30AM BLOOD Triglyc-144 HDL-47 CHOL/HD-3.3 LDLcalc-80
[**2116-3-21**] 09:30AM BLOOD TSH-0.65
CARDIAC ENZYMES
.
[**2116-3-21**] 09:30AM BLOOD ALT-18 AST-31 LD(LDH)-326* CK(CPK)-264*
AlkPhos-56 Amylase-65 TotBili-0.6
[**2116-3-21**] 02:40PM BLOOD CK(CPK)-837*
[**2116-3-22**] 12:20AM BLOOD CK(CPK)-244*
[**2116-3-22**] 06:00AM BLOOD CK(CPK)-606*
[**2116-3-23**] 05:15AM BLOOD CK(CPK)-PND
[**2116-3-21**] 09:30AM BLOOD CK-MB-26* MB Indx-9.8* cTropnT-0.21*
[**2116-3-21**] 02:40PM BLOOD CK-MB-88* MB Indx-10.5* cTropnT-2.04*
[**2116-3-22**] 12:20AM BLOOD CK-MB-88* MB Indx-36.1* cTropnT-3.95*
[**2116-3-22**] 06:00AM BLOOD CK-MB-65* MB Indx-10.7* cTropnT-3.54*
Digoxin levels
.
[**2116-3-21**] 09:30AM BLOOD Digoxin-5.0*
[**2116-3-22**] 06:00AM BLOOD Digoxin-4.5*
[**2116-3-23**] 05:15AM BLOOD Digoxin-3.2*
[**3-21**] TTE
The left atrium is elongated. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with focal basal inferior/inferolateral hypokinesis.
The remaining segments contract normally (LVEF = 50%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. There are focal calcifications in the aortic arch
and in the descending thoracic aorta. No dissection flap seen in
the aortic arch. The aortic valve leaflets (?number) are
moderately thickened. There is a minimally increased gradient
consistent with minimal aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Mild (1+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
IMPRESSION: Symmetric left ventricular hypertrophy with mild
regional systolic dysfunction, c/w CAD. Calcific aortic valve
disease with minimal stenosis and mild regurgitation. Diastolic
LV dysfunction with elevated filling pressures. Moderate
pulmonary hypertension.
.
Findings discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] at 1305 hours on the
day of the study.
[**3-21**] CXR
CHEST (PA & LAT)
.
Reason: mediastinal widening.
.
INDICATION: Possible aortic dissection. Evaluate for mediastinal
widening.
.
Mediastinal width is normal. The aorta is tortuous and
calcified. The heart is mildly enlarged, and there is slight
upper zone vascular redistribution, accompanied by vascular
indistinctness and a bilateral interstitial pattern affecting
the right lung to a greater degree than the left. Additionally,
there are subtle patchy areas of increased opacification in the
right mid and both lower lung regions. No pleural effusions or
acute skeletal abnormalities are identified.
.
IMPRESSION:
.
1. Diffusely tortuous and calcified thoracic aorta, but no
direct radiographic signs to suggest aortic dissection. Because
chest radiographs are not very sensitive for detecting
dissection, an MRA of the aorta could be considered given
clinical concern for avoiding iodinated contrast.
.
2. Cardiomegaly and asymmetrical parenchymal opacities that are
likely due to asymmetrical edema from CHF. Followup radiographs
after diuresis would be helpful to confirm resolution and to
exclude a more chronic interstitial abnormality.
CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2116-3-27**] 1:44 PM
.
CT CHEST POST-ADMINISTRATION OF INTRAVENOUS CONTRAST:
.
There are extensive increased interstitial markings throughout
both lungs. The appearances are suggestive of diffuse pulmonary
fibrosis. There are scattered pulmonary nodules within the
background interstitial change with the largest measuring 9 x 8
mm in the left lower lobe. There are several tiny mediastinal
lymph nodes with the largest measuring 17 x 10 mm. The pulmonary
arteries are enlarged. There is no definite pulmonary embolism.
There is coronary artery atherosclerosis present. There is
extensive calcified and noncalcified plaque in the aorta. There
is no pericardial or pleural effusion.
.
The liver and spleen appear unremarkable.
.
MUSCULOSKELETAL: There is a wedge compression through the
superior end plate of one of the mid-thoracic vertebral bodies.
There are no worrisome bone lesions.
.
CONCLUSION:
.
1. Extensive interstitial changes in the lungs are consistent
with diffuse fibrosis. There are several scattered pulmonary
nodules and enlarged mediastinal lymph nodes. A PET CT is
advised to rule out an underlying malignancy.
.
2. Enlarged pulmonary arteries suggestive of pulmonary arterial
hypertension. Coronary and aortic atherosclerosis is present.
.
The findings were added to the critical results communication
dashboard.

Cardiac cath [**2116-3-24**]: R dominant.
LMCA 40-50% with distal taper
LAD: modest diffuse calcification, no critical lesion
LCX; previous stent widely patent
RCA: dominant vessel with origin dampening and 70% with
mid-segment 60% hazy lesion.
Intervention: Cyper stent proximal RCA 70% lesions, POBA to
midsegment lesion.
[**2116-3-24**] CT ABD/PELVIS:
1.  No evidence of intraperitoneal or retroperitoneal hematoma.
2.  Retention of contrast within the renal cortices bilaterally.
 Correlation with the time of previous administration of
contrast is recommended as ATN cannot be excluded.  Segmental
lack of enhancement of thinned areas of renal cortex bilaterally
likely relates to chronic scarring.
3.  Cardiomegaly, coronary artery calcifications and pulmonary
edema.  Small bilateral pleural effusions.
4.  Sigmoid diverticulosis, without evidence of diverticulitis.
TTE [**2116-3-24**]
There is mild symmetric left ventricular hypertrophy. There is
mild regional left ventricular systolic dysfunction with
inferior hypokinesis. There is no ventricular septal defect.
There is mild global RV free wall hypokinesis. The aortic valve
leaflets are moderately thickened. The study is inadequate to
exclude significant aortic valve stenosis. Mild to moderate
([**12-25**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Mitral regurgitation is present but cannot
be quantified. There is no pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2116-3-21**], RV
systolic function is less vigorous.


Brief Hospital Course:
Mrs. [**Known lastname 3012**] is a 73 y/o F w/ hx of COPD, home o2 of 4L,
Paroxysmal Afib in NSR, not on anti-coagulation, moderate pulm
HTN, CAD s/p DES to OM1, CHF w/ EF of 50% who presents to OSH w/
nausea, vomiting, digoxin toxicity, Acute on Chronic renal
failure who was then transferred to [**Hospital1 18**] for [**10-2**] SSCP. SSCP
lasted for 30 min radiating to  the back, initial ? of aortic
disection at OSH. Patient arrived at [**Hospital1 18**], CTA not done because
of renal failure. No enlarged medistinum on CXR. TTE did not
show any AI. Discussed checking for Aortic disection on TEE, but
felt to be high risk if patient was ischemic, which we felt more
likely the case. Patient ruled in for an NSTEMI trop peak 3.95.
Kept on heparin for the first 48 hours as TIMI was 6. Viagra was
held, so that nitrates could be given.
.
On 3rd day, patient was taken to cardiac cath where successful
stenting of the ostial RCA was completed. PTCA of the mid RCA
also done, but unable to deploy stent. Post-cath one hour after
angioseal removal patient became hypotensive BP 60/40 and
hypoxic 77% on 4L. Patient mentating through out time period. A
code was called. Patient received fluids and BP came up to mid
90s. Patient was transferred to CCU for further monitoring.
Noted to have stable hct. No RP bleed on CT, no groin hematoma,
or other vascular access issue. Bedside TTE was done and there
was no signs of tamponade, but new RV dysfunction was noted.
Thought to be due to long procedure involving RCA where there
were time periods of diminished coronary flow. Patients anti-bp
meds, diltiazem, BB, hydralazine and nitrates were held. Pt
received 2.5 L of fluid in CCU. SBP in mid 80s then 90s. Called
out to the general cardiology wards. On that time on a much
reduced dose of lopressor. Patient was still relatively
hypotensive SBP in 90s on only one [**Doctor Last Name 360**], BP had been in 160s,
before on 4 bp agents. Concern that their might have been RV
infarct. BP meds held for this reason.
.
In the evening on [**3-26**] patient had a large amount of epistaxis,
followed by elevation in blood pressure to 200 mmHg and went
into atrial fibrillation with rapid ventricular response.  She
also became acutely short of breath.  RVR was controlled with
metoprolol.  It was felt that shortness of breath was due to
hypertension causing elevated filling pressures and pulmonary
edema.  Chest xray did not show significant pulmonary edema, but
this would not necessarily be expected during the acute event as
some time is required for transudate to develop. She was taken
to CCU where BP was controlled and patient was diuresed.
.
Patient came out to the general cardiology floor the following
evening, and then the next morning triggered for respiratory
distress and hypoxia 77% on 4L. She was placed on NRB, felt to
be fluid overloaded. Question of PNA on CXR pt received one day
of antibiotics, but on further pulm consultation not thought to
be pna and abx stopped. She had been maintained on IV heparin,
but still sub-therapeutic at times. Pt still had impaired renal
function w/ cr 1.4, but felt it necessary to r/o PE w/ CTA. No
pulmonary embolism on CTA. CT also showed multiple pulmonary
nodules, enlarged mediastinal lymphnodes and interstitial
markings consistent with fibrosis. The pulmonary team was
consulted for management of pulmonary issues and recommended
diuresis intially and the addition of CCB. Pt was diuresed w/
PRN IV lasix, but renal function worsened in the setting of
diuresis and dye load and becaome hypoinatremic, with rising
BUN. Over 3 days Cr 1.4=>2.3. Diuresis was stopped and renal fn
normalized. Patients BP, Resp, HR issues stabilized and she was
transferred to rehab.
.
Problems:
.
#Hypoxia: Problem at baseline at the time of d/c to rehab with
O2 sat >93% on 4L. Multifactorial due to COPD, moderate
pulmonary hypertension, question of underlying pulmonary
fibrosis based on CT scan. [**Month (only) 116**] also have had an element of fluid
overload after the MI as she appears to have improved somewhat
with diuresis but definitely dry on discharge with preserved EF
and no need for further diuresis. CCB started for HTN as well as
for pulmonary hypertension.  Viagra held given the hypotension
and MI but should be considered in f/u with her primary
pulmonologist although if she takes this will not be able to
take nitrates if has chest pain.
.
#COPD: Patient not felt to be in flare. Continued on home dose
of 10mg prednisone. Received ipratropium nebs and advair.
.
#NSTEMI: Patient ruled in for nstemi, trop max 3.95, DES to RCA
and PTCA of mid-rca. Patient continued on aspirin, plavix, bb,
atorvastatin 40mg.
.
#HTN: Hypotension and hypertension as in above narrative.
Patient BP regimen was modified to include a BB for post-MI
benefit and rate control as well as a CCB for pulm hypertension
and rate control.
.
#Acute on Chronic Diastolic CHF: Preserved EF >55%. BB and CCB
as above.
.
#Paroxsysmal Atrial Fibrillation: Patient was in NSR on
admission, discharge and most of hospitalization. During period
of BB withdrawal patient flipped into afib w/ RVR. Patient later
converted on her own. Patient was kept on heparin and bridged
over to coumadin and rate controlled with CCB and BB. ON this
regiment whe was maintained in NSR for most of the time and well
rate controlled.
.
#. Elevated Digoxin: Patient was noted to have elevated digoxin.
All dig was held while pt at [**Hospital1 18**]. Dig level of 5.0=>3.2,
trending down.
.
#. Acute on Chronic renal failure: On admission Cr 1.6 reported
to be 2.1 at OSH, patient received dye load from cath and CTA on
[**3-24**] and [**3-27**] respectively, and was overdiuresed causing renal
failure with Cr 1.4=>2.3 in matter of 3 days. At this point
diuretics were held with creatinine improving and at the time of
discharge ot was 2.0. Pls check in the next few days to make
sure this continues to improve.
.
#Pulmonary HTN: Held home viagra, so that nitrates could be
given instead w/ out risking synergy leading to hypotension.
.
#GERD: Cont Pantoprazole while inpatient
-episode of nausea and heart burn after eating yesterday [**3-23**]
.
#Full code
.
#Patient was evaluated by physical therapy who thought that
rehab was appropriate.
#Pt needs pulmonary, cardiac and PCP f/u within 2 weeks

Medications on Admission:
CURRENT MEDICATIONS:
MEDICATIONS
Advair 250/50 1puff [**Hospital1 **]
Spiriva 1mg daily
Nexium 40mg daily
Nitro-[**Hospital1 **] 6.5mg TID
Lipitor 40mg qhs
Lasix 20mg PO prn
Lopressor 25mg PO BID
ASA EC 325mg daily
[**Last Name (un) **]-dur 200mg PO BID
Cardizem 30mg PO TID
Prednisone 10mg daily
Plavix 75mg daily
Citracal unknown daily
Potassium 10mg daily
viagra 20mg TID
Cozaar ? PO daily
.


Discharge Medications:
1. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Primary Diagnosis:
NSTEMI
Elevated digoxin
Acute on Chronic Renal Failure
COPD
Pulmonary Artertial Hypertension
Diastolic Heart failure
Paroxysmal Atrial Fibrillation
.
Secondary Diagnosis
GERD
Hypertension


Discharge Condition:
Stable, 98% on 4L


Discharge Instructions:
Mrs. [**Known lastname 3012**] you were transferred to [**Hospital1 18**] out of concern for your
chest pain. You were found to have had a Non-ST elevation
myocardial infarction or heart attack. You were also noted to
have an abnormal elevation in your digoxin and worsening kidney
function.
.
Please keep all of your follow up appointment.
.
Please take all of your medications as prescribed.
.
We have given you sublingual nitroglycerin to take in the case
that you have another episode of chest pain. If you have chest
pain place one pill under your tongue every 5 minutes (ONLY IF
YOU HAVE NOT TAKEN ANY VIAGRA), until you have done this 3
times. If you have to do this please call 911.
.
Please call 911 or go to the Emergency Department if you develop
chest pain, worsening shortness of breath, or any other
worsening of your overall condition.

Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **] Jr,Ph#[**Telephone/Fax (1) 69287**], in the next two weeks.
.
Please follow up with your Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] in
the next 2 weeks. [**Street Address(2) 26336**], [**Location (un) 1468**], [**Numeric Identifier 11562**]  Phone:
([**Telephone/Fax (1) 5687**]
.
Please also schedule an appointment with your pulmonologist to
be seen within 2 weeks. [**First Name9 (NamePattern2) 69288**] [**Location (un) 20473**] [**Telephone/Fax (1) 69289**].
.
Please draw creatinine in the next couple of days and early next
week to make sure creatinine continues to improve.
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other chronic pulmonary heart diseases,Chronic kidney disease, unspecified,Hypoxemia,Other iatrogenic hypotension,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Peripheral vascular disease, unspecified,Aortic valve disorders,Esophageal reflux,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Cardiac catheterization 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: DATE: [**2116-3-21**]
.
OUTPATIENT CARDIOLOGIST: [**Last Name (LF) **],[**First Name3 (LF) **]
.
Chief Complaint: SSCP

PRESENT ILLNESS: HISTORY OF PRESENTING ILLNESS:
.
Patient is a 73 y/o F w/ a hx of CAD, s/p DES to OM1, [**7-29**], CHF
no echo on file, Paroxysmal Afib, not on anticoagulation, Severe
Pulmonary HTN on Viagra 20mg TID, hx of COPD home oxygen of 4L,
PVD, PUD, who presents on [**3-20**] to [**Hospital 487**] hospital with
Nausea/Vomiting, Abdominal Pain, Acute on Chronic renal failure
w/ Cr of 2.1, found to have BP in [**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] of 196/99, dig
level of 4.6, w/ 5mg IV morphine, 2.5mg IV lopressor w/
improvement of BP to 140/60 and HR in 90s. Nausea and vomiting
had been going on for 3 days prior to presentation.
.
Patient's N/V and Renal failure were thought to be secondary to
dig toxicity. An abdominal non-contrast CT scan was done which
showed no acute finding, atrophic R kidney, and sigmoid
diverticula. They suspected patients findings were secondary to
dig toxicity.
.
At 4am on [**3-21**] patient developed Severe [**10-2**] SSCP w/ radiation
to her back the pain continued for 30minutes. Patient was noted
to have ECG findings significant for 3mm ST depression in leads
v3-v6, 2mm ST elevation in AVR, 2-3mm downward sloping ST
depressions in leads 2, 3, avf. Patient was noted to have BP
183/88 in L arm and 155/97 in L arm.
.
Patient was transferred to [**Hospital1 18**] for work up of a possible
aortic dissection.

MEDICAL HISTORY: Percutaneous coronary intervention, in [**7-29**] anatomy as follows:

MEDICATION ON ADMISSION: CURRENT MEDICATIONS:
MEDICATIONS
Advair 250/50 1puff [**Hospital1 **]
Spiriva 1mg daily
Nexium 40mg daily
Nitro-[**Hospital1 **] 6.5mg TID
Lipitor 40mg qhs
Lasix 20mg PO prn
Lopressor 25mg PO BID
ASA EC 325mg daily
[**Last Name (un) **]-dur 200mg PO BID
Cardizem 30mg PO TID
Prednisone 10mg daily
Plavix 75mg daily
Citracal unknown daily
Potassium 10mg daily
viagra 20mg TID
Cozaar ? PO daily
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS - T 96.9, HR 90, BP L arm 170/90, R arm 160/80
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: NC

SOCIAL HISTORY: Patient quit smoking 10 years ago. She started at age 12 for a
greater than 50 pack year history. No etoh or illicit drugs.
Lives at home with husband. [**Name (NI) **] to complete daily ADLs. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other chronic pulmonary heart diseases,Chronic kidney disease, unspecified,Hypoxemia,Other iatrogenic hypotension,Cardiotonic glycosides and drugs of similar action causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Postinflammatory pulmonary fibrosis,Peripheral vascular disease, unspecified,Aortic valve disorders,Esophageal reflux,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
