CHIEF COMPLAINT: chest pain, arm pain

PRESENT ILLNESS: This is a 32 year-old with a PMH significant for HTN,
insulin-dependent diabetes mellitus who presents with a 3-day
history of chest and arm pain that developed with exertion with
some exertional dyspnea and fatigue.
.
The patient awoke Sunday ([**2154-1-13**]) feeling well and went to the
laundry mat walking 1-block with bags full of laundry and
developed some exertional dyspnea and left arm pain that
radiated in a pulsatile fashion to his fingers; without frank
chest pain, but with some diaphoresis. When he returned home,
his dyspnea improved with rest. However, his left arm pain
progressed to right arm pain even while resting. This pain
continued through Monday and early Tuesday morning he noted the
left arm pain was [**9-5**] in intensity and was sharp in character,
radiating to the left shoulder and back with some chest
discomfort that was constant. He presented to the BU Student
Health Center Tuesday PM and they gave him Aspirin 325 mg PO x 2
and called EMS. He was BIBA to the [**Hospital1 18**] ED for further
management.
.
In the ED, initial VS 102 114/85 20 99% 2LNC. An EKG showed
sinus tachycardia @ 119, NA/NI, 2-[**Street Address(2) 2051**]-elevations in lead
V2-6, 1-mm ST-elevations in leads aVL, I and inferior lead
reciprocal changes. He received Metoprolol 5 mg IV x 1, Heparin
bolus of 4000 units IV and Ativan 2 mg PO x 1. He was emergently
rushed to the cardiac cath [**Street Address(2) **] where the patient was noted to
have an abrupt cut-off at the mid-LAD with visible vessel
thrombus of the mid-LAD and distal reconstitution with
distal-LAD disease; underwent aspiration and ballooning of LAD
via RFA access (closed with angioseal). In the [**Street Address(2) **], he was given
Plavix 300 mg loading dose. Integrillin gtt was started and
heparin gtt was continued. In the cath [**Street Address(2) **] he was also
diaphoretic with a blood glucose of 390 mg/dL. He remained chest
pain free, but had on-going arm pain following the procedure.
.
On arrival in the CCU, the patient has some on-going left arm
pain while resting flat, but no chest pain, diaphoresis,
palpitations or nausea.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. No
change in bowel movements or bloody stools. Denies muscle
weakness, myalgias or neurologic complaints. No exertional
buttock or calf pain.

MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus (diagnosed at age 19
year-old - blood glucose runs in the 150-200 mg/dL range; takes
Lantus and Humalog)
2. Hypertension

MEDICATION ON ADMISSION: 1. Lantus 16 units SC at nighttime
2. Humalog 20 units SC prior to meals
3. Metformin 1000 mg PO BID
4. HCTZ 12.5 mg PO daily
5. Lisinopril 10 mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VITALS: 98.6 / 98.6  138/87  112  23  100% 2LNC
GENERAL: Appears in no acute distress. Alert and interactive
African American male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death. Strong family history of diabetes,
hypertension and stroke.

SOCIAL HISTORY: Patient lives at home with his wife, who is 9-weeks pregnant. He
denies any smoking history. He stopped drinking 8-years ago for
spiritual reasons. He is a BU graduate student who just moved
here from [**Location (un) 58091**], VA/DC for graduate school studying
practical theology. He notes significant stress related to
semester deadlines. He denies recreational substance use.
Acute myocardial infarction of anterolateral wall, initial episode of care,Unspecified disease of pericardium,Unspecified essential hypertension,Long-term (current) use of insulin,Heart disease, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Family history of stroke (cerebrovascular),Coronary atherosclerosis of native coronary artery,Obesity, unspecified
AMI anterolateral, init,Pericardial disease NOS,Hypertension NOS,Long-term use of insulin,Heart disease NOS,DMI wo cmp nt st uncntrl,Fam hx-cardiovas dis NEC,Fam hx-diabetes mellitus,Family hx-stroke,Crnry athrscl natve vssl,Obesity NOS
Admission Date:  [**2154-1-15**]              Discharge Date:   [**2154-1-19**]

Date of Birth:  [**2121-6-5**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, arm pain

Major Surgical or Invasive Procedure:
[**2154-1-15**] - Catheter placement, coronary thrombectomy, coronary
artery infusion of eptifibatide, Intravascular ultrasound,
Coronary Angiography
[**2154-1-18**] Coronary catheterization with placement of 2 bare metal
stents to mid LAD.


History of Present Illness:
This is a 32 year-old with a PMH significant for HTN,
insulin-dependent diabetes mellitus who presents with a 3-day
history of chest and arm pain that developed with exertion with
some exertional dyspnea and fatigue.
.
The patient awoke Sunday ([**2154-1-13**]) feeling well and went to the
laundry mat walking 1-block with bags full of laundry and
developed some exertional dyspnea and left arm pain that
radiated in a pulsatile fashion to his fingers; without frank
chest pain, but with some diaphoresis. When he returned home,
his dyspnea improved with rest. However, his left arm pain
progressed to right arm pain even while resting. This pain
continued through Monday and early Tuesday morning he noted the
left arm pain was [**9-5**] in intensity and was sharp in character,
radiating to the left shoulder and back with some chest
discomfort that was constant. He presented to the BU Student
Health Center Tuesday PM and they gave him Aspirin 325 mg PO x 2
and called EMS. He was BIBA to the [**Hospital1 18**] ED for further
management.
.
In the ED, initial VS 102 114/85 20 99% 2LNC. An EKG showed
sinus tachycardia @ 119, NA/NI, 2-[**Street Address(2) 2051**]-elevations in lead
V2-6, 1-mm ST-elevations in leads aVL, I and inferior lead
reciprocal changes. He received Metoprolol 5 mg IV x 1, Heparin
bolus of 4000 units IV and Ativan 2 mg PO x 1. He was emergently
rushed to the cardiac cath [**Street Address(2) **] where the patient was noted to
have an abrupt cut-off at the mid-LAD with visible vessel
thrombus of the mid-LAD and distal reconstitution with
distal-LAD disease; underwent aspiration and ballooning of LAD
via RFA access (closed with angioseal). In the [**Street Address(2) **], he was given
Plavix 300 mg loading dose. Integrillin gtt was started and
heparin gtt was continued. In the cath [**Street Address(2) **] he was also
diaphoretic with a blood glucose of 390 mg/dL. He remained chest
pain free, but had on-going arm pain following the procedure.
.
On arrival in the CCU, the patient has some on-going left arm
pain while resting flat, but no chest pain, diaphoresis,
palpitations or nausea.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. No
change in bowel movements or bloody stools. Denies muscle
weakness, myalgias or neurologic complaints. No exertional
buttock or calf pain.


Past Medical History:
1. Insulin-dependent diabetes mellitus (diagnosed at age 19
year-old - blood glucose runs in the 150-200 mg/dL range; takes
Lantus and Humalog)
2. Hypertension

Social History:
Patient lives at home with his wife, who is 9-weeks pregnant. He
denies any smoking history. He stopped drinking 8-years ago for
spiritual reasons. He is a BU graduate student who just moved
here from [**Location (un) 58091**], VA/DC for graduate school studying
practical theology. He notes significant stress related to
semester deadlines. He denies recreational substance use.


Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death. Strong family history of diabetes,
hypertension and stroke.

Physical Exam:
ADMISSION EXAM
VITALS: 98.6 / 98.6  138/87  112  23  100% 2LNC
GENERAL: Appears in no acute distress. Alert and interactive
African American male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
ADMISSION LABS:
.
[**2154-1-15**] 11:40AM BLOOD WBC-7.5 RBC-6.16 Hgb-14.6 Hct-46.1
MCV-75* MCH-23.7* MCHC-31.7 RDW-12.9 Plt Ct-244
[**2154-1-15**] 11:40AM BLOOD PT-11.5 PTT-27.3 INR(PT)-1.1
[**2154-1-15**] 11:40AM BLOOD Fibrino-572*
[**2154-1-15**] 08:00PM BLOOD UreaN-10 Creat-0.8 Na-130* K-4.1 Cl-97
[**2154-1-16**] 05:00AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
.
PERTINENT LABS AND STUDIES:
[**2154-1-15**] 08:00PM BLOOD CK(CPK)-387*
[**2154-1-16**] 05:00AM BLOOD CK(CPK)-275
[**2154-1-16**] 12:36PM BLOOD CK(CPK)-218
[**2154-1-15**] 08:00PM BLOOD CK-MB-7
[**2154-1-16**] 05:00AM BLOOD CK-MB-6 cTropnT-0.32*
[**2154-1-16**] 12:36PM BLOOD CK-MB-4 cTropnT-0.28*
[**2154-1-15**] 11:40AM BLOOD Lipase-35
[**2154-1-16**] 05:00AM BLOOD %HbA1c-11.5* eAG-283*
[**2154-1-16**] 05:00AM BLOOD Triglyc-180* HDL-35 CHOL/HD-3.4
LDLcalc-48 Cholest-119
.
[**2154-1-15**] CARDIAC CATH - French XBLAD3.5 guide provided good
support.  Crossed with Prowater very easily into the distal LAD.
 This did not restore flow in the apical LAD and visible
thrombus was seen to occlude
the vessel there.  Administered intracoronary Integrilin (180
mcg/kg x 2) and performed catheter based thrombectomy using the
Export catheter with significant clot removal/dissolution.
Administered intracoronary vasodilators. Perfomed intravascular
ultrasound using the Atlantis catheter and this revealed mild
diffuse atherosclerosis throughout the LAD and residual
subocclusive thrombus in the proximal LAD. A ChoICE PT XS [**Name (NI) **]
was redirected into various branches of the distal LAD and an
uninflated 2.0 mm balloon was used to "Dotter" across the apical
vessel clot, but this did not restore flow. It was decided that
we would administer 18 hours of integrilin and IV heparin for at
least 48 hours rather than cause distal embolization with stent,
balloon or rheolytic thrombectomy. Final angiography revealed
normal flow to the apical LAD where there was TIMI 0 flow and
filling via faint collaterals.  There was 20-40% residual
thrombus in the proximal LAD.  He left the laboratory in stable
condition with no chest pain.
.
[**2154-1-15**] CXR - The cardiomediastinal and hilar contours are
normal. The lungs are essentially clear. There is no pleural
effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process. [**2154-1-15**]
ECHOCARDIOGRAM The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-16**] 2D-ECHO - The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-18**] CARDIAC CATH:
Findings:
ESTIMATED blood loss: <100 cc
Hemodynamics (see above):
Coronary angiography:  left dominant
LMCA:  No angiographically-apparent CAD.
LAD:  Unchanged 60-80% subocclusive thrombus proximal LAD.
Visible thrombus in apical LAD with "train track" appearance
with
some flow in apex.
LCX:  No angiographically-apparent CAD.
RCA:  Not injected.  Known nondominant and free of disease.
.
Interventional details
XB3 guide.  Crossed with Prowater wire and performed IVUS
interrogation using the InfraredX catheter.  This demonstrated
significant thrombus in the proximal LAD with a RVD of 5.1 cm.
There was very little atheroma.   The decision was made to
proceed with direct stenting.  A 4.0 x 22 mm Integriti stent was
deployed and postdilated with a 5.0 mm balloon and residual
thrombus was visible distal to this stent and thought to be due
to uncovered (rather than due to prolapse or "toothpasting")
thrombus.  A distal overlapping 4.0 x 15 mm Integriti stent was
deployed and postdilated to 5.0 mm.  Final angiography revealed
normal flow, no dissection and 0% residual stenosis in the
stent,
no thrombus in the LAD up to the apex and no change in the
apical
LAD appearance.
.
Assessment & Recommendations
1.	Secondary prevention CAD, CHF.
2.	Plavix (clopidogrel) 75 mg daily X 12 months.
3.	Heparin at 1700 U/hr as bridge to therapeutic warfarin.
4.	Suggest warfarin INR [**3-1**].
5.	ASA 81 mg QD.
6.	Consider Cardiac MRI.
.
[**2154-1-19**] 2D-ECHO - The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of three days ago, [**2154-1-16**], the findings are
similar.


Brief Hospital Course:
32M with a PMH significant for HTN, insulin-dependent diabetes
mellitus who presents with a 3-day history of chest and arm pain
that developed with exertion with some exertional dyspnea and
fatigue found to have an anterolateral STEMI.
.
# ACUTE CORONARY SYNDROME, ST-SEGMENT ELEVATION MYOCARDIAL
INFARCTION - patient presented with acute coronary syndrome; no
prior history of chronic, stable angina but he has notable risk
factors including obesity, HTN, diabetes history and family
history. No prior cardiac catheterizations or known coronary
disease. EKG consistent with anterolateral ST-elevations with
cardiac catheterization showing abrupt cut-off at the mid-LAD
with visible vessel thrombus of the mid-LAD and distal
reconstitution with some distal-LAD disease; underwent
aspiration and balloon dottering of LAD via RFA access but given
the need to avoid distal embolization, anti-platelet therapy was
planned for 48-hours with a re-look planned. Received Aspirin
325 mg, Plavix 300 mg load, heparin IV 4000 unit bolus prior to
cath [**Year (4 digits) **] transfer. Integrillin and heparin gtt continued
following cardiac cath. Some on-going left arm pain and
persistent ST-elevations and TWI in the inferior leads following
the procedure resulted in starting Nitroglycerin gtt (evening of
[**1-15**]), which was discontinued. His re-look cardiac
catheterization procedure was performed on [**2154-1-18**] and showed
unchanged 60-80% sub-occlusive thrombus in the proximal LAD.
Visible thrombus in the apical LAD with "train track" appearance
with some flow in the apex was also noted. A 4.0 x 22 mm
Integrity stent was deployed and post-dilated with a 5.0 mm
balloon and residual thrombus was visible distal to this stent
and thought to be due to uncovered (rather than due to prolapse
or "toothpasting") thrombus. A distal overlapping 4.0 x 15 mm
Integrity stent was deployed and post-dilated to 5.0 mm.  Final
angiography revealed normal flow, no dissection and 0% residual
stenosis in the stent, no thrombus in the LAD up to the apex and
no change in the apical
LAD appearance. Heparin gtt was continued until Lovenox was
utilized and then the patient was bridged to Coumadin. He was
continued on Plavix (for 12-months), Aspirin, Metoprolol,
Atorvastatin for medical management of his coronary disease, as
an outpatient. He was also treated with Ibuprofen for suspected
pericarditis, given a pleuritic component of his chest pain.
.
# DIASTOLIC HEART DYSFUNCTION - No historical evidence of
systolic or diastolic dysfunction; no prior 2D-Echo reports and
no physical evidence of heart failure noted. Remains on an ACEI
given diabetes for renal protection as an outpatient. His
echocardiogram demonstrated no PFO or atrial septal defects and
his left ventricular function was read as normal with no global
systolic dysfunction (LVEF 55%). He did have evidence of
diastolic dysfunction (grade 2) and for this we continued his
ACEI therapy and he was maintained on a beta-blocker. A repeat
2D-Echo on [**1-19**] was unchanged. He had no indication for
diuresis and his weight was stable this admission.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - He has a history of
insulin-dependent diabetes mellitus diagnosed at age 19-years
when he presented unresponsive and was hospitalized. Has been on
insulin since and has blood glucose levels in the 150-200 mg/dL
range at home, per patient. No history HbA1c, but found to be an
HbA1c of 11.5% here. The patient required aggressive uptitration
of insulin given persistent hyperglycemia in the 400 mg/dL
range. At time of discharge, his blood glucose had improved
control with use of 18U Lantus and 20U short-acting insulin
prior to meals, resulting in blood glucoses of 150-170 mg/dL. He
will follow-up with [**Hospital **] [**Hospital 982**] clinic as an outpatient.
.
# HYPERTENSION - patient's home regimen included HCTZ and ACEI
therapy given his diabetes. We resumed his ACEI during this
hospitalization.
.
TRANSITION OF CARE ISSUES:
1. At the time of discharge, the following laboratory data,
microbiologic data and radiologic studies were pending.
2. Scheduled follow-up with his primary care physician and with
[**Name9 (PRE) **] [**Hospital 982**] clinic regarding the management of his
insulin-dependent diabetes.
3. Will require cardiac MR imaging and follow-up
echocardiography as an outpatient.
4. Will continue Lovenox bridge to Coumadin as an outpatient.
5. We started iron supplementation given his anemia.

Medications on Admission:
1. Lantus 16 units SC at nighttime
2. Humalog 20 units SC prior to meals
3. Metformin 1000 mg PO BID
4. HCTZ 12.5 mg PO daily
5. Lisinopril 10 mg PO daily

Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
2. insulin lispro 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous three times a day, prior to meals.
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

4. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Physical Therapy
Outpatient physical therapy for mechanical left shoulder pain.
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat every 5 minutes for a maximmum of 3 doses (15 minutes
of treatment).
Disp:*30 Tablet, Sublingual(s)* Refills:*1*
10. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
You labs will have to be drawn while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
11. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Continue until Dr. [**Last Name (STitle) 4427**]
tells you to stop.
Disp:*14 syringe* Refills:*0*
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
13. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Radiology
Cardiac MRI one month from discharge.
16. Outpatient Radiology
Outpatient Echo within the next month.
17. Outpatient [**Name (NI) **] Work
PT/INR on Wednesday [**2154-1-23**]. Please fax results to Dr. [**Last Name (STitle) 4427**]
at [**Hospital 18**] [**Hospital6 733**].


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
1. Acute anterolateral ST-segment elevation myocardial
infarction
2. Grade II, diastolic heart dysfunction
.
Secndary Diagnoses:
1. Insulin-dependent diabetes mellitus
2. Hypertension


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


Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
chest pain and shortness of breath. You were found to have an
anterolateral ST-segment elevation myocardial infarction (heart
attack) and went to the cardiac catheterization [**Hospital Ward Name **] urgently
where we attempted to remove the thrombus or clot in your heart
artery. You were medically managed with anti-platelet therapy
and anticoagulants following your first procedure and a second
catheterization was planned. This showed persistent clot in your
heart artery and required 2 bare metal stents be placed in that
artery. You chest pain resolved and you were monitored without
any additional events.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
Aspirin 325mg by mouth daily for one month.  Following this, you
should take 81mg by mouth daily.
Plavix (Clopidogrel) 75mg by mouth daily for 1 year
Metoprolol extended release 200mg by mouth daily
Nitroglycerin sublingually 0.4 as needed for chest pain
Atorvastatin 80mg by mouth daily
Lovenox 120mg injection twice daily until our primary care
doctor tells you to stop.
Warfarin 7.5mg by mouth daily at 4pm
Iron 300mg by mouth twice daily.
.
* The following medications were CHANGED on admission:
TAKE Lisinopril 20mg daily (you were previously on 10mg daily)
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.

You will need a follow up Cardiac MRI and echo.

Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) **] office to schedule a follow up
cardiology appointment. You should be seen by Dr. [**Last Name (STitle) 911**] in the
next 7-10days. His office can be reached at: ([**Telephone/Fax (1) 7283**].

Name: He, [**Name8 (MD) 91372**] MD
Location: [**Last Name (un) **] Diabetes Center
Address: [**Last Name (un) 3911**] [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 2384**]
Appointment: Wednesday [**2154-1-23**] 2:00pm
*Your appointment will be about 2-3 hours long. You will be
meeting with an educator as well as the doctor.
.
Primary Care:
Department: [**Hospital3 249**]
When: THURSDAY [**2154-1-24**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2154-2-20**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage





Name:  [**Known lastname 14369**],[**Known firstname 14370**]                Unit No:   [**Numeric Identifier 14371**]

Admission Date:  [**2154-1-15**]              Discharge Date:   [**2154-1-19**]

Date of Birth:  [**2121-6-5**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3373**]
Addendum:
ADDENDUM TO THE DISCHARGE SUMMARY FROM [**2154-1-19**]:
.
Per Dr. [**Last Name (STitle) 677**] (Interventional cardiologist), the patient should
continue on Lovenox with a bridge to Coumadin (INR goal [**3-1**]).
The anticoagulation should continue for a duration determined by
his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Dr. [**Last Name (STitle) 677**] will also see this
patient in clinic. Coumadin was started given the concern for a
thromboembolic source as the precursor to his thrombus formation
in the coronary arteries (however, no shunt or patent foramen
ovale was noted on 2D-Echo). Dr. [**Last Name (STitle) 677**] should be contact[**Name (NI) **]
regarding the need for bridging anticoagulation prior to
procedures. The patient was also given Lovenox teaching while
hospitalized and felt comfortable with the brigding strategy.
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1547**], MD


Discharge Disposition:
Home

                             [**First Name11 (Name Pattern1) 947**] [**Last Name (NamePattern4) 3374**] MD [**MD Number(2) 3375**]

Completed by:[**2154-1-19**]
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Unspecified disease of pericardium,Unspecified essential hypertension,Long-term (current) use of insulin,Heart disease, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Family history of stroke (cerebrovascular),Coronary atherosclerosis of native coronary artery,Obesity, 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: chest pain, arm pain

PRESENT ILLNESS: This is a 32 year-old with a PMH significant for HTN,
insulin-dependent diabetes mellitus who presents with a 3-day
history of chest and arm pain that developed with exertion with
some exertional dyspnea and fatigue.
.
The patient awoke Sunday ([**2154-1-13**]) feeling well and went to the
laundry mat walking 1-block with bags full of laundry and
developed some exertional dyspnea and left arm pain that
radiated in a pulsatile fashion to his fingers; without frank
chest pain, but with some diaphoresis. When he returned home,
his dyspnea improved with rest. However, his left arm pain
progressed to right arm pain even while resting. This pain
continued through Monday and early Tuesday morning he noted the
left arm pain was [**9-5**] in intensity and was sharp in character,
radiating to the left shoulder and back with some chest
discomfort that was constant. He presented to the BU Student
Health Center Tuesday PM and they gave him Aspirin 325 mg PO x 2
and called EMS. He was BIBA to the [**Hospital1 18**] ED for further
management.
.
In the ED, initial VS 102 114/85 20 99% 2LNC. An EKG showed
sinus tachycardia @ 119, NA/NI, 2-[**Street Address(2) 2051**]-elevations in lead
V2-6, 1-mm ST-elevations in leads aVL, I and inferior lead
reciprocal changes. He received Metoprolol 5 mg IV x 1, Heparin
bolus of 4000 units IV and Ativan 2 mg PO x 1. He was emergently
rushed to the cardiac cath [**Street Address(2) **] where the patient was noted to
have an abrupt cut-off at the mid-LAD with visible vessel
thrombus of the mid-LAD and distal reconstitution with
distal-LAD disease; underwent aspiration and ballooning of LAD
via RFA access (closed with angioseal). In the [**Street Address(2) **], he was given
Plavix 300 mg loading dose. Integrillin gtt was started and
heparin gtt was continued. In the cath [**Street Address(2) **] he was also
diaphoretic with a blood glucose of 390 mg/dL. He remained chest
pain free, but had on-going arm pain following the procedure.
.
On arrival in the CCU, the patient has some on-going left arm
pain while resting flat, but no chest pain, diaphoresis,
palpitations or nausea.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. No
change in bowel movements or bloody stools. Denies muscle
weakness, myalgias or neurologic complaints. No exertional
buttock or calf pain.

MEDICAL HISTORY: 1. Insulin-dependent diabetes mellitus (diagnosed at age 19
year-old - blood glucose runs in the 150-200 mg/dL range; takes
Lantus and Humalog)
2. Hypertension

MEDICATION ON ADMISSION: 1. Lantus 16 units SC at nighttime
2. Humalog 20 units SC prior to meals
3. Metformin 1000 mg PO BID
4. HCTZ 12.5 mg PO daily
5. Lisinopril 10 mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VITALS: 98.6 / 98.6  138/87  112  23  100% 2LNC
GENERAL: Appears in no acute distress. Alert and interactive
African American male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death. Strong family history of diabetes,
hypertension and stroke.

SOCIAL HISTORY: Patient lives at home with his wife, who is 9-weeks pregnant. He
denies any smoking history. He stopped drinking 8-years ago for
spiritual reasons. He is a BU graduate student who just moved
here from [**Location (un) 58091**], VA/DC for graduate school studying
practical theology. He notes significant stress related to
semester deadlines. He denies recreational substance use. 

### Response:
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Unspecified disease of pericardium,Unspecified essential hypertension,Long-term (current) use of insulin,Heart disease, unspecified,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Family history of other cardiovascular diseases,Family history of diabetes mellitus,Family history of stroke (cerebrovascular),Coronary atherosclerosis of native coronary artery,Obesity, unspecified'}
