CHIEF COMPLAINT: CAD s/p cath with evolving hematoma

PRESENT ILLNESS: Mrs. [**Known lastname 45917**] is a 75 year old woman with hypertension, CHF with
diastolic dysfunction, PAF, type II diabetes, prior MI, lung
cancer and s/p partial lung resection who was hospitalized at
[**Hospital1 18**] from [**2188-12-13**] to [**2188-12-23**] for SOB and cough. She was
treated for a CHF exacerbation as well as pneumonia. At the time
of admission, she had hypertensive urgency with systolic blood
pressures in the 200 range. She developed flash pulmonary edema
requiring intubation x 3 days. Post intubation, she subsequently
developed several episodes of hyptertension, requiring a nitro
gtt. A renal ultrasound was negative for renal artery stenosis.
Urinary metanephrines were also sent to rule out pheochomocytoma
and were negative. Transient ischemic changes were noted on EKG
during her hypertensive episodes. Troponin levels were elevated
to a peak of 0.77 but CPK??????s were negative. An [**Month/Day/Year 113**] done on
[**2188-12-13**] revealed hyperdynamic systolic function. There was
severe mitral annular calcification and moderate thickening of
the mitral valve chordae with at least mild to moderate [**1-21**]+
mitral regurgitation. Small pericardial effusion.
.
A pMIBI done in [**12/2187**] was negative for perfusion defects and
showed an EF of 54%
.
Following discharge, the patient was seen by Dr. [**Last Name (STitle) **] on
[**2189-1-19**]. At that time, she was complaining of swelling in both
hands and legs as well as in her face. She was also complaining
of 3 pillow orthopnea at that time. She denises any PND. She
denies any lightheadedness. She denies any claudication
symptoms. She continues to have swelling her legs but reports
that the swelling in her hands and face has improved. She
reports having one episode of chest pain the other night after
dinner. She said it occurred intermittently at rest over a few
hours and then finally resolved spontaneously. She denies having
any associated symptoms and states that this is the only episode
of chest pain she has had since her hospitalization.

MEDICAL HISTORY: Cardiac risk factors: Diabetes, Hypertension
.
Cardiac History: no prior CABG, PCI, or PPM
.
PMH:
Pneumonia [**12-27**]
Hypertension
Diabetes II
Lung cancer s/p partial resection [**2179**]
TAH/BSO
Anxiety
Chronic urticaria/hives
Venous stasis
Restless leg syndrome
Chronic Renal Failure
Mild to moderate mitral regurgitation
Paroxysmal Atrial fibrillation on coumadin
Cholecystectomy
Milk ducts removed
Cyst removed from buttocks
Eye surgery for glaucoma
Cataract surgery

MEDICATION ON ADMISSION: Coumadin, MWF 5mg, 6mg other days, last dose [**2189-1-25**]
Aspirin 162mg daily in the am
Lasix 40mg, 2 tablets in am, 1 tablet in the PM
Metoprolol XL 100mg daily in the am
Hydralazine 75mg TID
Glyburide 2.5mg [**Hospital1 **]
Cosupt eye gtts 1 gtt right eye [**Hospital1 **]
Colace 100mg 1-2 times daily
Imdur 60mg 2.5 tablets daily
Pravastatin 40mg daily in the PM
Xalatan eye gtts 1 gtt both eye qhs
Lorazepam 1mg Qhs
Trazadone 25mg qhs
Sertraline 75mg daily qhs

ALLERGIES: Zestril / Maxaquin / Norvasc / Percocet

PHYSICAL EXAM: VS: 99.8 144/50 53 19 97% on 1.5L
General: Anxious appearing female in NAD
HEENT: NCAT, MMM, o/p clear
CV: RR, nl s1/s2
LUNGS: Clear anteriorly, unable to auscultate posteriorly due to
hematoma
ABD: Soft, NTND, NABS, no flank tenderness
Ext: Large groin hematoma, currently with pressure dressing in
place, palpable distal pulses bilaterally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Peripheral vascular complications, not elsewhere classified,Congestive heart failure, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute respiratory failure,Chronic kidney disease, Stage III (moderate),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aneurysm of artery of lower extremity,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Atrial fibrillation,Family history of ischemic heart disease,Personal history of malignant neoplasm of bronchus and lung,Other specified hypotension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Crnry athrscl natve vssl,Acute kidney failure NOS,Surg comp-peri vasc syst,CHF NOS,Hematoma complic proc,Ac posthemorrhag anemia,Urin tract infection NOS,Acute respiratry failure,Chr kidney dis stage III,DMII renl nt st uncntrld,Lower extremity aneurysm,Enterococcus group d,Inf mcr rst ot drg nt ml,Atrial fibrillation,Fam hx-ischem heart dis,Hx-bronchogenic malignan,Hypotension NEC,Hy kid NOS w cr kid I-IV
Admission Date:  [**2189-1-30**]              Discharge Date:   [**2189-2-7**]

Date of Birth:  [**2113-5-27**]             Sex:   F

Service: MEDICINE

Allergies:
Zestril / Maxaquin / Norvasc / Percocet

Attending:[**First Name3 (LF) 2962**]
Chief Complaint:
CAD s/p cath with evolving hematoma

Major Surgical or Invasive Procedure:
- Cardiac catheterization and bare metal stent to LAD
- Surgical repair of pseudoaneurysm

History of Present Illness:
Mrs. [**Known lastname 45917**] is a 75 year old woman with hypertension, CHF with
diastolic dysfunction, PAF, type II diabetes, prior MI, lung
cancer and s/p partial lung resection who was hospitalized at
[**Hospital1 18**] from [**2188-12-13**] to [**2188-12-23**] for SOB and cough. She was
treated for a CHF exacerbation as well as pneumonia. At the time
of admission, she had hypertensive urgency with systolic blood
pressures in the 200 range. She developed flash pulmonary edema
requiring intubation x 3 days. Post intubation, she subsequently
developed several episodes of hyptertension, requiring a nitro
gtt. A renal ultrasound was negative for renal artery stenosis.
Urinary metanephrines were also sent to rule out pheochomocytoma
and were negative. Transient ischemic changes were noted on EKG
during her hypertensive episodes. Troponin levels were elevated
to a peak of 0.77 but CPK??????s were negative. An [**Month/Day/Year 113**] done on
[**2188-12-13**] revealed hyperdynamic systolic function. There was
severe mitral annular calcification and moderate thickening of
the mitral valve chordae with at least mild to moderate [**1-21**]+
mitral regurgitation. Small pericardial effusion.
.
A pMIBI done in [**12/2187**] was negative for perfusion defects and
showed an EF of 54%
.
Following discharge, the patient was seen by Dr. [**Last Name (STitle) **] on
[**2189-1-19**]. At that time, she was complaining of swelling in both
hands and legs as well as in her face. She was also complaining
of 3 pillow orthopnea at that time. She denises any PND. She
denies any lightheadedness. She denies any claudication
symptoms. She continues to have swelling her legs but reports
that the swelling in her hands and face has improved. She
reports having one episode of chest pain the other night after
dinner. She said it occurred intermittently at rest over a few
hours and then finally resolved spontaneously. She denies having
any associated symptoms and states that this is the only episode
of chest pain she has had since her hospitalization.


Past Medical History:
Cardiac risk factors: Diabetes, Hypertension
.
Cardiac History: no prior CABG, PCI, or PPM
.
PMH:
Pneumonia [**12-27**]
Hypertension
Diabetes II
Lung cancer s/p partial resection [**2179**]
TAH/BSO
Anxiety
Chronic urticaria/hives
Venous stasis
Restless leg syndrome
Chronic Renal Failure
Mild to moderate mitral regurgitation
Paroxysmal Atrial fibrillation on coumadin
Cholecystectomy
Milk ducts removed
Cyst removed from buttocks
Eye surgery for glaucoma
Cataract surgery


Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.


Family History:
Non-contributory

Physical Exam:
VS: 99.8 144/50 53 19 97% on 1.5L
General: Anxious appearing female in NAD
HEENT: NCAT, MMM, o/p clear
CV: RR, nl s1/s2
LUNGS: Clear anteriorly, unable to auscultate posteriorly due to
hematoma
ABD: Soft, NTND, NABS, no flank tenderness
Ext: Large groin hematoma, currently with pressure dressing in
place, palpable distal pulses bilaterally


Pertinent Results:
[**2189-1-30**] 10:00AM BLOOD WBC-9.2 RBC-3.64* Hgb-11.1* Hct-31.6*
MCV-87 MCH-30.5 MCHC-35.0 RDW-15.6* Plt Ct-305
[**2189-1-31**] 05:22AM BLOOD WBC-7.9 RBC-3.05* Hgb-8.7* Hct-26.0*
MCV-85 MCH-28.7 MCHC-33.6 RDW-14.5 Plt Ct-247
[**2189-2-1**] 05:08AM BLOOD WBC-8.8 RBC-2.87* Hgb-8.4* Hct-24.4*
MCV-85 MCH-29.1 MCHC-34.2 RDW-14.2 Plt Ct-214
[**2189-2-1**] 12:45PM BLOOD WBC-11.1* RBC-3.20* Hgb-9.6* Hct-27.7*
MCV-86 MCH-30.1 MCHC-34.8 RDW-15.1 Plt Ct-246
[**2189-2-1**] 05:25PM BLOOD WBC-9.8 RBC-3.10* Hgb-9.2* Hct-26.6*
MCV-86 MCH-29.8 MCHC-34.7 RDW-14.2 Plt Ct-175
[**2189-2-2**] 10:20AM BLOOD WBC-10.3 RBC-3.40* Hgb-9.9* Hct-29.3*
MCV-86 MCH-29.3 MCHC-33.9 RDW-15.4 Plt Ct-224
[**2189-2-2**] 09:17PM BLOOD WBC-15.1* RBC-3.48* Hgb-10.4* Hct-30.1*
MCV-87 MCH-30.0 MCHC-34.7 RDW-15.4 Plt Ct-281
[**2189-2-3**] 05:47AM BLOOD WBC-11.5* RBC-3.53* Hgb-10.5* Hct-30.5*
MCV-86 MCH-29.6 MCHC-34.3 RDW-15.2 Plt Ct-265
[**2189-2-4**] 06:13AM BLOOD WBC-6.0 RBC-3.06* Hgb-9.0* Hct-26.6*
MCV-87 MCH-29.6 MCHC-34.0 RDW-15.2 Plt Ct-225
[**2189-2-5**] 07:15AM BLOOD WBC-6.8 RBC-2.98* Hgb-8.8* Hct-26.2*
MCV-88 MCH-29.6 MCHC-33.6 RDW-15.2 Plt Ct-241
[**2189-2-5**] 06:10PM BLOOD WBC-7.1 RBC-3.01* Hgb-8.8* Hct-26.5*
MCV-88 MCH-29.2 MCHC-33.2 RDW-15.0 Plt Ct-224
[**2189-2-6**] 07:15AM BLOOD WBC-6.8 RBC-3.13* Hgb-9.1* Hct-27.3*
MCV-87 MCH-29.1 MCHC-33.2 RDW-15.0 Plt Ct-227
[**2189-1-30**] 10:00AM BLOOD PT-13.2 INR(PT)-1.1
[**2189-1-31**] 05:22AM BLOOD PT-14.9* PTT-31.1 INR(PT)-1.3*
[**2189-2-1**] 05:08AM BLOOD PT-13.5* PTT-29.3 INR(PT)-1.2*
[**2189-2-2**] 10:20AM BLOOD PT-13.1 PTT-28.7 INR(PT)-1.1
[**2189-2-2**] 09:17PM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1
[**2189-2-3**] 05:47AM BLOOD PT-13.3 PTT-28.0 INR(PT)-1.1
[**2189-2-4**] 06:13AM BLOOD PT-13.9* PTT-30.8 INR(PT)-1.2*
[**2189-1-30**] 10:00AM BLOOD Glucose-183* UreaN-44* Creat-1.3* Na-142
K-4.0 Cl-103 HCO3-26 AnGap-17
[**2189-1-31**] 05:22AM BLOOD Glucose-58* UreaN-42* Creat-1.4* Na-142
K-3.6 Cl-103 HCO3-28 AnGap-15
[**2189-2-1**] 05:08AM BLOOD Glucose-94 UreaN-54* Creat-2.6*# Na-138
K-3.7 Cl-100 HCO3-28 AnGap-14
[**2189-2-1**] 12:45PM BLOOD Glucose-195* UreaN-54* Creat-2.9* Na-136
K-3.9 Cl-101 HCO3-25 AnGap-14
[**2189-2-1**] 05:25PM BLOOD Glucose-94 UreaN-56* Creat-3.0* Na-137
K-4.3 Cl-101 HCO3-23 AnGap-17
[**2189-2-2**] 10:20AM BLOOD Glucose-191* UreaN-60* Creat-3.5* Na-134
K-4.5 Cl-99 HCO3-23 AnGap-17
[**2189-2-2**] 09:17PM BLOOD Glucose-169* UreaN-64* Creat-3.8* Na-136
K-4.7 Cl-101 HCO3-24 AnGap-16
[**2189-2-3**] 05:47AM BLOOD Glucose-156* UreaN-67* Creat-4.0* Na-134
K-4.7 Cl-99 HCO3-24 AnGap-16
[**2189-2-4**] 06:13AM BLOOD Glucose-81 UreaN-70* Creat-3.6* Na-137
K-3.6 Cl-102 HCO3-26 AnGap-13
[**2189-2-4**] 05:10PM BLOOD Glucose-113* UreaN-70* Creat-3.1* Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2189-2-5**] 07:15AM BLOOD Glucose-123* UreaN-69* Creat-2.7* Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2189-2-5**] 06:10PM BLOOD Glucose-140* UreaN-69* Creat-2.5* Na-138
K-4.1 Cl-102 HCO3-26 AnGap-14
[**2189-2-6**] 07:15AM BLOOD Glucose-132* UreaN-67* Creat-2.1* Na-139
K-4.0 Cl-104 HCO3-26 AnGap-13
[**2189-1-30**] 09:49PM BLOOD CK(CPK)-56
[**2189-1-31**] 05:22AM BLOOD CK(CPK)-48
[**2189-2-2**] 09:17PM BLOOD CK(CPK)-73
[**2189-2-3**] 05:47AM BLOOD CK(CPK)-72
[**2189-2-2**] 09:17PM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2189-2-3**] 05:47AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2189-1-31**] 05:22AM BLOOD Calcium-8.0* Phos-4.7* Mg-2.3
[**2189-2-1**] 05:08AM BLOOD Calcium-8.1* Phos-5.3* Mg-2.3
[**2189-2-1**] 12:45PM BLOOD Calcium-7.8* Phos-5.7* Mg-2.3
[**2189-2-1**] 05:25PM BLOOD Calcium-8.3* Phos-5.8* Mg-2.4
[**2189-2-2**] 10:20AM BLOOD Calcium-8.0* Phos-6.5* Mg-2.2
[**2189-2-2**] 09:17PM BLOOD Calcium-8.2* Phos-7.1* Mg-2.3
[**2189-2-3**] 05:47AM BLOOD Calcium-8.5 Phos-7.5* Mg-2.4
[**2189-2-4**] 06:13AM BLOOD Calcium-8.1* Phos-6.5* Mg-2.3
[**2189-2-4**] 05:10PM BLOOD Calcium-8.2* Phos-5.0* Mg-2.4
[**2189-2-5**] 07:15AM BLOOD Calcium-7.8* Phos-4.1 Mg-2.4
[**2189-2-5**] 06:10PM BLOOD Calcium-8.1* Phos-3.7 Mg-2.4
[**2189-2-6**] 07:15AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.4
[**2189-2-3**] 05:47AM BLOOD C3-131 C4-45*
.
[**2189-1-31**] 6:43 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2189-2-3**]**

   URINE CULTURE (Final [**2189-2-3**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------     8 S
LINEZOLID-------------     2 S
NITROFURANTOIN--------    64 I
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------  =>32 R
.
CT ABD/Pelvis [**2189-1-30**]:
IMPRESSION:
1. Large hematoma within the anterior subcutaneous soft tissues
of the proximal right thigh. Pseudoaneurysm seen on ultrasound
appears to lie laterally to the hematoma and the relationship to
the femoral vasculature is not well demonstrated on this non-
contrast- enhanced CT.
2. No retroperitoneal hematoma present.
.
FEMORAL VASCULAR US RIGHT

Reason: PSA, AVF.

[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with hematoma, bruit right groin.
REASON FOR THIS EXAMINATION:
PSA, AVF.
INDICATION: 75-year-old woman with hematoma and bruit of the
right groin after recent catheterization.

No comparison is available.

TECHNIQUE AND FINDINGS: [**Doctor Last Name **] scale, color flow and Doppler
images of the right groin area were obtained. There is a mostly
anechoic lesion within the lateral groin which, based on the
internal color flow pattern, is consistent with a pseudoaneurysm
measuring approximately 3.4 x 1.9 x 1.7 cm. A [**Location (un) 45918**] of the
pseudoaneurysm is identified which measures approximately 4 mm
in diameter. The relationship of this pseudoaneurysm to the
common and superficial femoral artery is not clear on the images
provided. A large focus of hematoma is noted medial to the
pseudoaneurysm measuring approximately 5.7 x 1.7 x 1.6 cm.

IMPRESSION: Pseudoaneurysm within the right groin. The
relationship of the pseudoaneurysm to the adjacent common
femoral and superficial femoral arteries is not clear at this
time, and a [**Location (un) 45918**] to the common femoral artery is possible.
A follow-up ultrasound to better delineate the relationship of
the pseudoaneurysm to the adjacent vessels may be of benefit.
.
FEMORAL VASCULAR US RIGHT  [**2189-1-31**] 2:19 PM

FEMORAL VASCULAR US RIGHT

Reason: HX PSEUDO PLEASE EVAL FOR INTERVAL CHANGE

[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with pseudo-aneurysm and hematoma noted on
ultrasound of [**1-30**].
REASON FOR THIS EXAMINATION:
Please evaluate for interval change. Also please try to
determine vessel of origin and neck.
HISTORY: 75-year-old female with right groin pseudoaneurysm and
hematoma seen on ultrasound from [**2189-1-30**]. Please evaluate for
interval change.

FINDINGS: Targeted ultrasound was performed in the patient's
right groin in the area of known hematoma and pseudoaneurysm.

Pseudoaneurysm in the right groin currently measures 3.5 x 5.5 x
2.4 cm, and measured 3.4 x 1.9 x 1.7 cm one day earlier, now
with areas of increased internal grayscale echogenicity seen
superolaterally, likely thrombus. Color Doppler evaluation
continues to demonstrate swirling internal vascularity,
consistent with pseudoaneurysm.

On current study, the neck is well visualized and evaluated,
approximately 6 mm at its origin, and approximately 1.6 cm in
length, arising off the anterior aspect of the common femoral
artery.

Again seen medial to the pseudoaneurysm is a large groin
hematoma, which measures 6.0 x 2.9 x 5.7 cm., unchanged.

IMPRESSION:

1. Slight increase in size of long-necked pseudoaneurysm arising
from the right common femoral artery in the right groin,
although exact comparison is difficult given the interval
formation of echogenic material consistent with thrombus within
the pseudoaneurysm.

2. Unchanged appearance of hematoma medial to the
pseudoaneurysm.
.
RENAL U.S. PORT; DUPLEX DOPP ABD/PEL

Reason: please eval for hydro, and please do dopplers to
emaluate re

[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with DM, CAD, diastolic CHF who now has acute
on chronic renal failure after cath on [**1-30**] complicated by bleed
from pseudoaneurysm
REASON FOR THIS EXAMINATION:
please eval for hydro, and please do dopplers to emaluate renal
arteries
RENAL ULTRASOUND ON [**2-3**]

CLINICAL HISTORY: Renal failure, acute on chronic. Question
hydro.

FINDINGS: Grayscale and color Doppler ultrasound imaging of the
kidneys was performed. The kidneys maintain normal size with
slightly echogenic cortices. The right kidney measures 11.1 cm,
the left kidney measures 10.8 cm. There is no hydronephrosis.
There is a large 3.6-cm right lower pole cyst. Otherwise, the
contours are smooth.

Doppler analysis of the renal vascular system reveals markedly
elevated resistance internally, with resistive indices
approximating 1.0. Renal veins remain patent.

IMPRESSION: No hydronephrosis. Somewhat echogenic kidneys, and
elevated resistive indices.
.
[**Month/Year (2) **] [**2189-2-3**]:
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small-to-moderate sized
pericardial effusion, primarily posterior to the RA and around
the LV, without echocardiographic signs of tamponade.

IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Mild pulmonary
hypertension. Small-to-moderate pericardial effusion.

Compared with the prior study (images reviewed) of [**2188-12-13**],
elevated RA pressures and mild pulmonary hypertension are
identified. The other findings are similar.
.
CXR [**2189-2-5**]:
IMPRESSION: Progressive improvement in pulmonary edema.
Persistent bilateral effusions, left worse than right, with
ongoing left base atelectasis.
.
Cath [**2189-1-30**]:
COMMENTS:
1. Coronary angiography in this right dominant system
revealed severe single vessel disease. The LMCA had no
significant
disease. The LAD had a calcified mid 70-80% stenosis. The LCx
had a
calcified proximal 40-50% stenosis. The RCA had mild luminal
irregularities.
2. Limited resting hemodynamics revealed an elevated left sided
filling
pressure with LVEDP of 26 mmHg. There was severe arterial
systemic
systolic hypertension with SBP of 238 mmHg.
3. Left ventriculography was deferred.
4. Successful stenting of mid LAD with MiniVision 2.5x18mm stent

post-dilated proximally to 2.75mm.
5.  Renal angiography revealed 30% stenosis on right and no
disease on
left.
6.  During sheath pull patient developed sizable hematoma
requiring
blood transfusion.  She also developed a pseudoaneurysm which
required
surgical repair 2 days after the cath.

FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Severe left ventricular diastolic dysfunction.
3. Successful stenting of mid LAD with bare metal stent.
4. No renal artery stenosis.
5. Cath complicated by hematoma and pseudoaneurysm requiring
surgical
repair.


Brief Hospital Course:
# Coronary artery disease: The patient was initially admitted to
the CMI service for catheterization to evaluate for coronary
artery disease.  She had a BMS placed to her LAD. Status post
BMS to LAD as above. Cath complicated by evolving
hematoma/pseudoaneurysm, see below.  She was continued on
aspirin and plavix for the next 30 days. She is to discontinue
her coumadin for that time. Once plavix is discontinued, she
will restart coumadin at her prior home dose. She was
additionally continued on her statin.  She was discharged on her
home regimen of metoprolol.
.
# Right groin pseudoaneurysm: On post-cath check was noted to
have a new bruit. This was evaluated by femoral ultrasound and
the patient was found to have a large pseudoaneurysm.
Initially, this was stable. Over the next 24 hours, patient
required 3 units of prbcs. She was reevaluated and on repeat US
was found to have an enlarging hematoma. Vascular surgery was
consulted and the pseudoaneurysm was repaired in the OR.  After
repair, the hematoma was stable and her Hct continued to improve
for the duration of her hospitalization. She will follow up with
Dr. [**Last Name (STitle) 1391**] in 2 weeks for staple removal. This appointment has
been arranged for her.
.
# Hypertensive Urgency/Respiratory distress: On [**2-2**], in the
setting of decreasing urine output, the patient began to become
anxious, and her systolic blood pressure was found to be in the
200s. She began to develop respiratory distress.  She was
emergently started on a nitro drip in the setting of flash
pulmonary edema from hypertensive urgency and diastolic
dysfunction. Her blood pressure was sustained in the 200s and a
code blue was called. The patient was intubated and taken to the
CCU. She was then transiently hypotensive with sBP in the 70s
likely secondary to sedation given during intubation, and
required peripheral dopamine overnight.  She was successfullly
extubated on [**2189-2-3**]. Her pulmonary edema improved as did her
blood pressure.  She was transferred back to the medical floor
on [**2189-2-4**].
.
# Acute Renal Failure: Patient began to develop increasing
creatinine and low urine output 2 days after her catheterization
after her pseudoaneurysm repair. Baseline creatinine 1.3-1.5,
and reached a peak of 4.  This was thought to be a combination
of contrast-induced nephropathy combined with hypovolemia as a
result of acute blood loss from her pseudoaneurysm.  She was
initially started on a lasix drip in the setting of low urine
output and volume overload after her flash pulmonary edema. Her
creatinine began to improve over time as did her urine ouput. A
renal ultrasound was done which showed no evidence of
hydronephrosis and a renal angiogram was negative for RAS. Her
creatinine had returned to near baseline prior to discharge.
.
# Pump: [**Date Range **] during this admission showing LVEF>55%.  History of
chronic diastolic dysfuction.  She will be discharged on her
home regimen of Lasix.
.
# Valves: 1+ MR [**First Name (Titles) **] [**Last Name (Titles) **] this admission, no current issues.
.
# Rhythm: History of paroxysmal afib, now in sinus. On coumadin
as an outpatient.  As per Dr. [**Last Name (STitle) **], she will continue ASA,
plavix for 30 days, resume coumadin once discontinues plavix. No
telemetry events.
.
# Anemia: Baseline Hct of 28-30 with Hct prior to cath 31.6. Has
been stable and increasing since pseudoaneurysm repair.  Near
baseline at the time of discharge.
.
# UTI: Patient was found to have a VRE UTI during her admission.
She was started on IV Ampicillin based on sensitivities and is
discharged on Amoxicillin to complete a 10 day course of
antibiotics.  She should have a repeat UA once she has been
treated to confirm complete resolution of her UTI.
.
# Agitation/anxiety: Patient has significant anxiety at
baseline. Takes ativan qhs at home with occasional prn doses.
During her last admission, 1mg IV ativan caused increased
agitation. She was started on oxazepam 15mg qhs with once daily
prn dosing for anxiety attacks as well as sertraline 50mg qhs.
Currently on ativan PO and sertraline 75 qhs.  She was continued
on her outpatient regimen.
.
# DM II: ISS during admission. On Glyburide at home. Last HgbA1c
6.6 in [**9-27**]. Restarted on home regimen on discharge.
.
# Code - FULL
.
# Contact: [**Name (NI) 4906**] [**Name (NI) 45919**] [**Telephone/Fax (1) 45920**].


Medications on Admission:
Coumadin, MWF 5mg, 6mg other days, last dose [**2189-1-25**]
Aspirin 162mg daily in the am
Lasix 40mg, 2 tablets in am, 1 tablet in the PM
Metoprolol XL 100mg daily in the am
Hydralazine 75mg TID
Glyburide 2.5mg [**Hospital1 **]
Cosupt eye gtts 1 gtt right eye [**Hospital1 **]
Colace 100mg 1-2 times daily
Imdur 60mg 2.5 tablets daily
Pravastatin 40mg daily in the PM
Xalatan eye gtts 1 gtt both eye qhs
Lorazepam 1mg Qhs
Trazadone 25mg qhs
Sertraline 75mg daily qhs


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*4*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: 2.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
11. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).

12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DINNER
(Dinner).
13. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
14. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
15. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Imdur 60 mg Tablet Sustained Release 24 hr Sig: 2.5 Tablet
Sustained Release 24 hrs PO once a day.
17. Amoxicillin 500 mg Tablet Sig: One (1) Tablet PO three times
a day for 6 days.
Disp:*18 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
Bear [**Doctor Last Name **] Nursing Ctr.

Discharge Diagnosis:
CAD
Hypertension
Chronic diastolic dysfunction
Vancomycin-resistant UTI
Right groin pseudoaneurysm status post repair


Discharge Condition:
Hemodynamically stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 liter/daily.

Please take Aspirin and Plavix for 1 month.  Please hold
Coumadin for this duration then restart coumadin once you have
completed your plavix.

While you were here, you were found to have a blockage in one of
your coronary arteries which was opened. You then developed a
collection of blood in your leg (pseudoaneurysm). You had this
repaired surgically, and it has been stable. You should not do
any strenuous activity for the next few weeks.

In addition, your kidney function decreased while you were here.
It has been steadily improving. However, you should follow up
with a Nephrologist as below when you are discharged to follow
your kidney function.

You were also found to have a urinary tract infection. Please
take your Amoxicillin as prescribed. You should have a repeat
urine test once you have completed your antibiotics to make sure
that you have cleared your infection. Your primary care doctor
can do this for you.

We have discontinued your hydralazine since your blood pressure
has been lower while you were here. You should follow up with
your primary care doctor to determine if you need this
medication or not.
If you develop any chest pain, leg pain, shortness of breath,
decrease in your urine amounts, or any other symptom that
concerns you, please seek medical attention immediately.

Followup Instructions:
Please keep the following follow up appointments:

Cardiology: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2189-5-7**] at 4:30pm. The phone
number there is ([**Telephone/Fax (1) 7236**].

Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB)
Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2189-2-16**] 9:10

Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] on Wednesday, [**2-25**] at 2:30 pm for
staple removal. Please call his office at ([**Telephone/Fax (1) 4852**] with
any questions.

In addition, you should follow up with a Nephrologist to further
evaluate your renal function. You can call ([**Telephone/Fax (1) 773**] to set
up this appointment.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2964**] MD, [**MD Number(3) 2965**]
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Peripheral vascular complications, not elsewhere classified,Congestive heart failure, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute respiratory failure,Chronic kidney disease, Stage III (moderate),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aneurysm of artery of lower extremity,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Atrial fibrillation,Family history of ischemic heart disease,Personal history of malignant neoplasm of bronchus and lung,Other specified hypotension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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



### Clinical text :
CHIEF COMPLAINT: CAD s/p cath with evolving hematoma

PRESENT ILLNESS: Mrs. [**Known lastname 45917**] is a 75 year old woman with hypertension, CHF with
diastolic dysfunction, PAF, type II diabetes, prior MI, lung
cancer and s/p partial lung resection who was hospitalized at
[**Hospital1 18**] from [**2188-12-13**] to [**2188-12-23**] for SOB and cough. She was
treated for a CHF exacerbation as well as pneumonia. At the time
of admission, she had hypertensive urgency with systolic blood
pressures in the 200 range. She developed flash pulmonary edema
requiring intubation x 3 days. Post intubation, she subsequently
developed several episodes of hyptertension, requiring a nitro
gtt. A renal ultrasound was negative for renal artery stenosis.
Urinary metanephrines were also sent to rule out pheochomocytoma
and were negative. Transient ischemic changes were noted on EKG
during her hypertensive episodes. Troponin levels were elevated
to a peak of 0.77 but CPK??????s were negative. An [**Month/Day/Year 113**] done on
[**2188-12-13**] revealed hyperdynamic systolic function. There was
severe mitral annular calcification and moderate thickening of
the mitral valve chordae with at least mild to moderate [**1-21**]+
mitral regurgitation. Small pericardial effusion.
.
A pMIBI done in [**12/2187**] was negative for perfusion defects and
showed an EF of 54%
.
Following discharge, the patient was seen by Dr. [**Last Name (STitle) **] on
[**2189-1-19**]. At that time, she was complaining of swelling in both
hands and legs as well as in her face. She was also complaining
of 3 pillow orthopnea at that time. She denises any PND. She
denies any lightheadedness. She denies any claudication
symptoms. She continues to have swelling her legs but reports
that the swelling in her hands and face has improved. She
reports having one episode of chest pain the other night after
dinner. She said it occurred intermittently at rest over a few
hours and then finally resolved spontaneously. She denies having
any associated symptoms and states that this is the only episode
of chest pain she has had since her hospitalization.

MEDICAL HISTORY: Cardiac risk factors: Diabetes, Hypertension
.
Cardiac History: no prior CABG, PCI, or PPM
.
PMH:
Pneumonia [**12-27**]
Hypertension
Diabetes II
Lung cancer s/p partial resection [**2179**]
TAH/BSO
Anxiety
Chronic urticaria/hives
Venous stasis
Restless leg syndrome
Chronic Renal Failure
Mild to moderate mitral regurgitation
Paroxysmal Atrial fibrillation on coumadin
Cholecystectomy
Milk ducts removed
Cyst removed from buttocks
Eye surgery for glaucoma
Cataract surgery

MEDICATION ON ADMISSION: Coumadin, MWF 5mg, 6mg other days, last dose [**2189-1-25**]
Aspirin 162mg daily in the am
Lasix 40mg, 2 tablets in am, 1 tablet in the PM
Metoprolol XL 100mg daily in the am
Hydralazine 75mg TID
Glyburide 2.5mg [**Hospital1 **]
Cosupt eye gtts 1 gtt right eye [**Hospital1 **]
Colace 100mg 1-2 times daily
Imdur 60mg 2.5 tablets daily
Pravastatin 40mg daily in the PM
Xalatan eye gtts 1 gtt both eye qhs
Lorazepam 1mg Qhs
Trazadone 25mg qhs
Sertraline 75mg daily qhs

ALLERGIES: Zestril / Maxaquin / Norvasc / Percocet

PHYSICAL EXAM: VS: 99.8 144/50 53 19 97% on 1.5L
General: Anxious appearing female in NAD
HEENT: NCAT, MMM, o/p clear
CV: RR, nl s1/s2
LUNGS: Clear anteriorly, unable to auscultate posteriorly due to
hematoma
ABD: Soft, NTND, NABS, no flank tenderness
Ext: Large groin hematoma, currently with pressure dressing in
place, palpable distal pulses bilaterally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Peripheral vascular complications, not elsewhere classified,Congestive heart failure, unspecified,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Acute respiratory failure,Chronic kidney disease, Stage III (moderate),Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aneurysm of artery of lower extremity,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Atrial fibrillation,Family history of ischemic heart disease,Personal history of malignant neoplasm of bronchus and lung,Other specified hypotension,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
