CHIEF COMPLAINT: chest pain, hypotension

PRESENT ILLNESS: 77 yo male with history of coronary artery disease, PBH, recent
prostate biopsy and recent dental work presented with substernal
chest pain, with ED course complicated by hypotension.
.
Chest pain began last night after eating an apple. Worse with
movement and with inspiration, radiates to his neck, associated
with dyspnea and nausea, but no vomiting. No diaphoresis. The
pain does not radiate to his back. He is unsure if this pain is
same as his prior cardiac pain. His wife gave him simethicone-
the pain persisted, and given his history, she gave him aspirin
and sublingual nitroglycerin, without change in pain. He was
then transferred to [**Hospital1 18**] ED via ambulance.
.
Of note, his PCP recently check his PSA, which was elevated at
5.7. He saw Dr. [**Last Name (STitle) **], who performed a TURP about five years ago.
The patient has recently had a prostate biopsy within the past
two weeks, which showed localized prostate cancer. Next
management steps were to be discussed on [**2104-12-23**].
.
He also reports having recent dental work in the past two weeks,
and has an implanted piece of gold in his upper teeth. Prior to
dental work, he was pretreated with one dose of amoxicillin.
.
In the ED, initial VS were: 99.7 70 102/54 18 97% RA
[x] EKG - sinus rhythm at 65, normal intervals, TWI in III is
old, other NSST changes unchanged from prior
[x] bedside echo no effusion
Rectal exam- no blood, non-tender prostate
.
Patient was ready to be admitted to floor, and vitals were:
100.9 76/40 61 18
CVL placed, 3 liters total, CVP 8-9, and was started on
noripenephrine to maintain MAP > 60. He received pip/tazo 4.5
grams x 1 anc vanc 1 gram x 1. UOP 500 cc.
.
On arrival to the MICU, patient reported chronic neck, back and
leg pain. He reported some gassy pain, relieved with belching.
.
Review of systems:
(+) Per HPI
(-) Denies recent fevers, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. He does endorse chroinc arthralgias related to
arthritis. Denies rashes or skin changes.

MEDICAL HISTORY: CAD, status post previous CABG [**2085-10-13**] status post PTCA/stent
of distal LCX and mid LCX [**2096-10-12**]. Recurrent atypical chest,
with normal p-mibi in [**7-/2104**]
Recent prostate biopsy, which showed prostate cancer ->
subsequent PET CT did not show evidence of metastatic disease
BPH s/p TURP about five years ago
hypertension
hyperlipidemia
obesity
complicated gallbladder surgery
chronic back pain
gout

MEDICATION ON ADMISSION: ALLOPURINOL - 300 mg Tablet daily
FLUOXETINE - 20 mg Capsule daily
METOPROLOL SUCCINATE 25 mg daily
NITROGLYCERIN - 2.5 mg Capsule, Extended Release - 1 Capsule(s)
by mouth every 12 hours
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes up to 3 tablets for chest pain
OXAZEPAM 10 mg Capsule - 2 Capsule(s) by mouth at bedtime
OXYCODONE - 5 mg Tablet - Q 4-6 hours PRN pain
OXYCODONE [OXYCONTIN] - 10 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily in the morning and 1 at night
PRIMIDONE - 50 mg Tablet daily
SIMVASTATIN - 40 mg daily
SUCRALFATE 2 grams by mouth QAM and HS
URSODIOL - 300 mg Capsule - two Capsule(s) [**Hospital1 **]
VALSARTAN 40 mg Tablet daily
ASPIRIN 325 mg Tablet daily
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Tablet daily
OMEGA-3 FATTY ACIDS-FISH OIL

ALLERGIES: Tetanus / Azithromycin

PHYSICAL EXAM: Vitals: T 97.8 HR 54 BP 115/51 95 % 2 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Dentures in upper teeth, with gold piece in right upper teeth.
Neck: supple, JVP not elevated, no LAD. Right IJ in place.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar rales that clear with inspiration. No wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.

FAMILY HISTORY: Sister died from CVA, father died at 54 from MI, brother with MI
at 80

SOCIAL HISTORY: Patient lives in [**Location 1268**] with his wife. Originally from
[**Location (un) 20338**], [**Country 2559**]. Worked as a cabinet maker. Smokes [**3-20**] pipes of
tobacco a day. Glass of wine daily.
Malignant neoplasm of prostate,Anemia, unspecified,Examination of participant in clinical trial,Percutaneous transluminal coronary angioplasty status,Other adrenal hypofunction,Acute edema of lung, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,Unspecified essential hypertension
Malign neopl prostate,Anemia NOS,Exam-clincal trial,Status-post ptca,Adrenal hypofunction NEC,Acute lung edema NOS,Cor ath unsp vsl ntv/gft,Hyperlipidemia NEC/NOS,Hypertension NOS
Admission Date:  [**2104-12-19**]              Discharge Date:   [**2104-12-26**]

Date of Birth:  [**2027-11-11**]             Sex:   M

Service: MEDICINE

Allergies:
Tetanus / Azithromycin

Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
 chest pain, hypotension

Major Surgical or Invasive Procedure:
None


History of Present Illness:
77 yo male with history of coronary artery disease, PBH, recent
prostate biopsy and recent dental work presented with substernal
chest pain, with ED course complicated by hypotension.
.
Chest pain began last night after eating an apple. Worse with
movement and with inspiration, radiates to his neck, associated
with dyspnea and nausea, but no vomiting. No diaphoresis. The
pain does not radiate to his back. He is unsure if this pain is
same as his prior cardiac pain. His wife gave him simethicone-
the pain persisted, and given his history, she gave him aspirin
and sublingual nitroglycerin, without change in pain. He was
then transferred to [**Hospital1 18**] ED via ambulance.
.
Of note, his PCP recently check his PSA, which was elevated at
5.7. He saw Dr. [**Last Name (STitle) **], who performed a TURP about five years ago.
The patient has recently had a prostate biopsy within the past
two weeks, which showed localized prostate cancer. Next
management steps were to be discussed on [**2104-12-23**].
.
He also reports having recent dental work in the past two weeks,
and has an implanted piece of gold in his upper teeth. Prior to
dental work, he was pretreated with one dose of amoxicillin.
.
In the ED, initial VS were: 99.7 70 102/54 18 97% RA
[x] EKG - sinus rhythm at 65, normal intervals, TWI in III is
old, other NSST changes unchanged from prior
[x] bedside echo no effusion
Rectal exam- no blood, non-tender prostate
.
Patient was ready to be admitted to floor, and vitals were:
100.9 76/40 61 18
CVL placed, 3 liters total, CVP 8-9, and was started on
noripenephrine to maintain MAP > 60. He received pip/tazo 4.5
grams x 1 anc vanc 1 gram x 1. UOP 500 cc.
.
On arrival to the MICU, patient reported chronic neck, back and
leg pain. He reported some gassy pain, relieved with belching.
.
Review of systems:
(+) Per HPI
(-) Denies recent fevers, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. He does endorse chroinc arthralgias related to
arthritis. Denies rashes or skin changes.

Past Medical History:
CAD, status post previous CABG [**2085-10-13**] status post PTCA/stent
of distal LCX and mid LCX [**2096-10-12**]. Recurrent atypical chest,
with normal p-mibi in [**7-/2104**]
Recent prostate biopsy, which showed prostate cancer ->
subsequent PET CT did not show evidence of metastatic disease
BPH s/p TURP about five years ago
hypertension
hyperlipidemia
obesity
complicated gallbladder surgery
chronic back pain
gout

Social History:
Patient lives in [**Location 1268**] with his wife. Originally from
[**Location (un) 20338**], [**Country 2559**]. Worked as a cabinet maker. Smokes [**3-20**] pipes of
tobacco a day. Glass of wine daily.

Family History:
Sister died from CVA, father died at 54 from MI, brother with MI
at 80


Physical Exam:
Vitals: T 97.8 HR 54 BP 115/51 95 % 2 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Dentures in upper teeth, with gold piece in right upper teeth.
Neck: supple, JVP not elevated, no LAD. Right IJ in place.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar rales that clear with inspiration. No wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.

Pertinent Results:
Admission Labs:
[**2104-12-19**] 05:00AM BLOOD WBC-7.0 RBC-3.71* Hgb-12.2* Hct-36.0*
MCV-97 MCH-32.8* MCHC-33.8 RDW-13.2 Plt Ct-194
[**2104-12-19**] 05:00AM BLOOD Neuts-52.7 Lymphs-39.0 Monos-4.5 Eos-3.1
Baso-0.7
[**2104-12-19**] 05:00AM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2104-12-19**] 05:00AM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-136
K-4.2 Cl-99 HCO3-29 AnGap-12
[**2104-12-19**] 05:00AM BLOOD ALT-6 AST-16 LD(LDH)-126 AlkPhos-77
TotBili-0.3
[**2104-12-19**] 05:00AM BLOOD Lipase-23
[**2104-12-19**] 05:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-1.6
[**2104-12-19**] 05:00AM BLOOD cTropnT-<0.01
[**2104-12-19**] 05:59PM BLOOD cTropnT-<0.01
[**2104-12-19**] 05:31AM BLOOD Lactate-0.6
[**2104-12-19**] 07:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.033
[**2104-12-19**] 07:20AM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2104-12-19**] 07:20AM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2104-12-19**] 07:20AM URINE CastHy-9*
.
Discharge Labs:
[**2104-12-24**] 06:55AM BLOOD WBC-4.8 RBC-3.49* Hgb-11.0* Hct-33.4*
MCV-96 MCH-31.6 MCHC-33.1 RDW-13.3 Plt Ct-209
[**2104-12-25**] 06:53AM BLOOD Glucose-85 UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-99 HCO3-31 AnGap-11
[**2104-12-22**] 07:30AM BLOOD Cortsol-2.6
[**2104-12-23**] 01:30PM BLOOD Cortsol-2.4
[**2104-12-23**] 02:10PM BLOOD Cortsol-11.0
[**2104-12-24**] 04:05PM BLOOD Cortsol-5.9
[**2104-12-24**] 05:18PM BLOOD Cortsol-22.5*
.
PENDING LABS:  ACTH, Free Cortisol, Renin, Aldosterone from
[**2104-12-24**]
.
Microbiology:
Blood Cultures 11/4 and [**12-21**]: No growth (final)
Urine Culture [**12-19**]: No growth (final)
Catheter Tip culture [**12-21**]: No growth (final)
Influenza DFA [**12-19**]: Negative
.
IMAGING:
CTA Chest [**2104-12-19**]: The thyroid gland is unremarkable. There is
no axillary or mediastinal
lymphadenopathy by CT size criteria. The heart and greater
vessels are
unremarkable. There is mild coronary artery calcifications. No
pericardial
effusions are present. The pulmonary arteries are patent down to
the
subsegmental level. The lungs show minimal bibasilar atelectasis
and a small
focus of scarring in the left upper lobe, unchanged since [**2097**].
A 2 mm and 4
mm nodule in the right upper lobe is unchanged since the
previous examination.
No other nodules, effusions or consolidations are present. The
patient is
status post a coronary artery bypass grafting.
Although this examination was not intended for subdiaphragmatic
evaluation,
the partially imaged abdomen shows a granuloma in the right lobe
of the liver
and a calcified right adrenal nodule, unchanged. The patient is
status post
cholecystectomy.
OSSEOUS STRUCTURES:
The visible osseous structures show no suspicious lytic or
blastic lesions or
fractures. There is mild scoliosis of the thoracic spine.
IMPRESSION:
No acute intrathoracic process.
.
CT Abd/Pelvis [**2104-12-19**]: 1. No acute intra-abdominal process.
2. Diverticulosis, but no diverticulitis.
3. Atherosclerotic disease of the coronary arteries and
intra-abdominal
aorta.
4. Scoliosis and degenerative changes of the lumbar spine.
.
TTE [**2104-12-22**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild aortic
regurgitation. Pulmonary artery hypertension. Dilated ascending
aorta.
Compared with the report of the prior study (images unavailable
for review) of [**2096-10-12**], the ascending aorta is slightly larger
and mild PA systolic hypertension is now identified. The other
findings are similar.
CLINICAL IMPLICATIONS:
Based on [**2100**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
CXR [**2104-12-24**]:  In comparison with the study of [**12-19**], the cardiac
silhouette is
less prominent and the pulmonary vascularity is substantially
improved. Mild
atelectatic changes are seen at the bases.

Brief Hospital Course:
Mr. [**Known lastname 99802**] is a 77 yo M with a hx of CAD s/p CABG, HTN, HL,
recent diagnosis of prostate cancer who presented to the MICU
with chest pain and hypotension.
.
# Hypotension: Initially, the patient's hypotension in the
setting of low grade fevers was concerning for a septic
etiology.  However, he only required pressors transiently, and
his blood pressure improved significantly with fluid
resuscitation.  He was started on Unasyn, as possible sources of
infection were thought to be GU and oropharyngeal (patient had
recent prostate biopsy and dental work).   Unasyn was stopped
when infectious workup remained unrevealing.  He was ruled out
for an MI and a PE.  After transfer to the medicine floor, the
patient's BP remained low but stable.  A morning cortisol was
low, as was a cortisol stimulation test, raising concern for
adrenal insufficiency.  The endocrinology service was consulted,
and performed another cortisol stimulation test; several
portions of this test were pending at discharge, and the patient
planned to follow up in endocrine clinic in several weeks.  He
was started on hydrocortisone 15 mg in the AM and 5 mg in the PM
for presumed partial adrenal insufficiency, with a plan for
endocrine to taper steroids after the patient is seen in clinic.

.
# Fevers: During his stay in the MICU, the patient had low grade
fevers.  However, no sources of infection were found.  Workup
included urine culture, blood cultures, influenza DFA, CT
abdomen and pelvis and CTA chest.  Additionally, the patient
underwent TTE to evaluate for culture negative endocarditis, and
no vegetations were seen.  His fevers resolved several days
after admission, and he had been afebrile > 72 hours at the time
of discharge.
.
# Chest pain:  The patient initially presented with chest pain,
which persisted throughout his hospitalization.  He was ruled
out for PE, and cardiac enzymes were negative.  He did have
subtle ECG changes when he was hypotensive on admission, and he
might benefit from repeat stress testing with imaging as an
outpatient.
.
# Anemia - The patient had a Hct drop from 36 to 31; this was
felt to be multifactorial from dilution after fluid
resuscitation, phlebotomy and ongoing hematuria related to
prostate cancer and recent prostate biopsy.
.
# Hypoxia - After fluid resuscitation the patient had a small
oxygen requirement.  CXR showed interstitial edema and he
received several doses of oral furosemide with good urine
output.  At discharge, his oxygen requirement had resolved and
his ambulatory O2 saturation was in the mid-90s.
.
# Prostate Ca - Patient reported a recent diagnosis of prostate
cancer, with a plan to follow-up with Dr. [**Last Name (STitle) 365**] as an outpatient.
.
# HTN - Anti hypertensives were initially held secondary to the
patient's hypotension, but low dose metoprolol was restarted on
discharge.
.
# CAD - Patient was continued on ASA.  Metoprolol initially
held, but restarted on discharge.
.
# Spinal Stenosis: Continued on home oxycontin and prn
oxycodone.


Medications on Admission:
ALLOPURINOL - 300 mg Tablet daily
FLUOXETINE - 20 mg Capsule daily
METOPROLOL SUCCINATE 25 mg daily
NITROGLYCERIN - 2.5 mg Capsule, Extended Release - 1 Capsule(s)
by mouth every 12 hours
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes up to 3 tablets for chest pain
OXAZEPAM 10 mg Capsule - 2 Capsule(s) by mouth at bedtime
OXYCODONE - 5 mg Tablet - Q 4-6 hours PRN pain
OXYCODONE [OXYCONTIN] - 10 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily in the morning and 1 at night
PRIMIDONE - 50 mg Tablet daily
SIMVASTATIN - 40 mg daily
SUCRALFATE 2 grams by mouth QAM and HS
URSODIOL - 300 mg Capsule - two Capsule(s) [**Hospital1 **]
VALSARTAN 40 mg Tablet daily
ASPIRIN 325 mg Tablet daily
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Tablet daily
OMEGA-3 FATTY ACIDS-FISH OIL

Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. sucralfate 1 gram Tablet Sig: Two (2) Tablet PO twice a day.

10. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
11. hydrocortisone 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
Disp:*90 Tablet(s)* Refills:*2*
12. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Partial Adrenal Insufficiency
Hypotension
Acute pulmonary edema


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 99802**],

You were admitted to the hospital with low blood pressure and
chest discomfort.  Your blood pressure medications were held,
you were given IV fluids and your blood pressure improved.  You
were seen by endocrinology while in the hospital, and they think
that you may have a partial deficiency in cortisol.  You have an
appointment to see endocrinology in clinic to discuss whether
you will need any treatment for this condition.
.
We made the following changes to your home medications:
STOP Nitroglycerin
STOP Ursodiol
STOP Valsartan
START Hydrocortisone, 15 mg in the morning and 5 mg in the PM
around 2pm

Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2104-12-29**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS     Best Parking: On Street Parking

Department: MEDICAL SPECIALTIES-Endocrinology
When: MONDAY [**2105-1-12**] at 4:20 PM
With: DR. [**Last Name (STitle) **] & ZHIHENG [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
{'Malignant neoplasm of prostate,Anemia, unspecified,Examination of participant in clinical trial,Percutaneous transluminal coronary angioplasty status,Other adrenal hypofunction,Acute edema of lung, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,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, hypotension

PRESENT ILLNESS: 77 yo male with history of coronary artery disease, PBH, recent
prostate biopsy and recent dental work presented with substernal
chest pain, with ED course complicated by hypotension.
.
Chest pain began last night after eating an apple. Worse with
movement and with inspiration, radiates to his neck, associated
with dyspnea and nausea, but no vomiting. No diaphoresis. The
pain does not radiate to his back. He is unsure if this pain is
same as his prior cardiac pain. His wife gave him simethicone-
the pain persisted, and given his history, she gave him aspirin
and sublingual nitroglycerin, without change in pain. He was
then transferred to [**Hospital1 18**] ED via ambulance.
.
Of note, his PCP recently check his PSA, which was elevated at
5.7. He saw Dr. [**Last Name (STitle) **], who performed a TURP about five years ago.
The patient has recently had a prostate biopsy within the past
two weeks, which showed localized prostate cancer. Next
management steps were to be discussed on [**2104-12-23**].
.
He also reports having recent dental work in the past two weeks,
and has an implanted piece of gold in his upper teeth. Prior to
dental work, he was pretreated with one dose of amoxicillin.
.
In the ED, initial VS were: 99.7 70 102/54 18 97% RA
[x] EKG - sinus rhythm at 65, normal intervals, TWI in III is
old, other NSST changes unchanged from prior
[x] bedside echo no effusion
Rectal exam- no blood, non-tender prostate
.
Patient was ready to be admitted to floor, and vitals were:
100.9 76/40 61 18
CVL placed, 3 liters total, CVP 8-9, and was started on
noripenephrine to maintain MAP > 60. He received pip/tazo 4.5
grams x 1 anc vanc 1 gram x 1. UOP 500 cc.
.
On arrival to the MICU, patient reported chronic neck, back and
leg pain. He reported some gassy pain, relieved with belching.
.
Review of systems:
(+) Per HPI
(-) Denies recent fevers, chills, night sweats, recent weight
loss or gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. He does endorse chroinc arthralgias related to
arthritis. Denies rashes or skin changes.

MEDICAL HISTORY: CAD, status post previous CABG [**2085-10-13**] status post PTCA/stent
of distal LCX and mid LCX [**2096-10-12**]. Recurrent atypical chest,
with normal p-mibi in [**7-/2104**]
Recent prostate biopsy, which showed prostate cancer ->
subsequent PET CT did not show evidence of metastatic disease
BPH s/p TURP about five years ago
hypertension
hyperlipidemia
obesity
complicated gallbladder surgery
chronic back pain
gout

MEDICATION ON ADMISSION: ALLOPURINOL - 300 mg Tablet daily
FLUOXETINE - 20 mg Capsule daily
METOPROLOL SUCCINATE 25 mg daily
NITROGLYCERIN - 2.5 mg Capsule, Extended Release - 1 Capsule(s)
by mouth every 12 hours
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually every 5 minutes up to 3 tablets for chest pain
OXAZEPAM 10 mg Capsule - 2 Capsule(s) by mouth at bedtime
OXYCODONE - 5 mg Tablet - Q 4-6 hours PRN pain
OXYCODONE [OXYCONTIN] - 10 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily in the morning and 1 at night
PRIMIDONE - 50 mg Tablet daily
SIMVASTATIN - 40 mg daily
SUCRALFATE 2 grams by mouth QAM and HS
URSODIOL - 300 mg Capsule - two Capsule(s) [**Hospital1 **]
VALSARTAN 40 mg Tablet daily
ASPIRIN 325 mg Tablet daily
CHOLECALCIFEROL (VITAMIN D3) 2,000 unit Tablet daily
OMEGA-3 FATTY ACIDS-FISH OIL

ALLERGIES: Tetanus / Azithromycin

PHYSICAL EXAM: Vitals: T 97.8 HR 54 BP 115/51 95 % 2 liters n/c
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
Dentures in upper teeth, with gold piece in right upper teeth.
Neck: supple, JVP not elevated, no LAD. Right IJ in place.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bibasilar rales that clear with inspiration. No wheezes,
rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.

FAMILY HISTORY: Sister died from CVA, father died at 54 from MI, brother with MI
at 80

SOCIAL HISTORY: Patient lives in [**Location 1268**] with his wife. Originally from
[**Location (un) 20338**], [**Country 2559**]. Worked as a cabinet maker. Smokes [**3-20**] pipes of
tobacco a day. Glass of wine daily. 

### Response:
{'Malignant neoplasm of prostate,Anemia, unspecified,Examination of participant in clinical trial,Percutaneous transluminal coronary angioplasty status,Other adrenal hypofunction,Acute edema of lung, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Other and unspecified hyperlipidemia,Unspecified essential hypertension'}
