CHIEF COMPLAINT: Elective PCI for three-vessel disease complicated by dissection
of Left Main

PRESENT ILLNESS: This 75 year old woman has a history of obesity, hypertension,
dyslipidemia, CAD and [**Location (un) 3484**] syndrome with longstanding
steroid use and subsequent development of DM. On [**2132-10-16**] she
underwent cardiac catheterization at [**Hospital3 2358**] [**2-26**] anginal sx
and an abnormal ETT. Angiography revealed three vessel disease
with a 50%stenosis of the RCA, 40% LM, 80-90% stenosis of her
OM1 and OM2, and a 90% stenosis of distal LAD. LVEF was noted at
60%.
.
She has since been evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from cardiac
surgery. Studies have revealed no usable lower extremity veins
for CABG. In addition, it is felt that Mrs.[**Known lastname 24469**] is quite
high
risk for sternal complications.  Plans were for PCI of the RCA,
OM1 and OM2 by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] with possible LIMA to LAD by
CTsurg at a later date.
.
During her catherization today her RCA was stented and while
trying to stent the OM's the Left Main was dissected then
stented. She denies any chest pain, and her EKG was not
concerning for evolving MI. Biomarkers were negative int he
immediate post-procedure period.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- [**Location (un) **] disease s/p ablation of pituitary adenoma at [**Hospital1 2025**].
- Hip replacement for osteoarthritis.
- Obesity.
- Lower back pain.
- Status post right knee patella removal after motor vehicle
accident.
- History of left lower leg hematoma after a fall 3 years ago.
- Depression.
- Hypothyroidism.
- Deep vein thrombosis in left calf 3 years ago.
- Cataract in both eyes status post extraction.

MEDICATION ON ADMISSION: ALPRAZOLAM -  (Prescribed by Other Provider) - 0.5 mg Tablet -
[**1-28**] Tablet(s) by mouth once a day
AMLODIPINE [NORVASC] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
BUMETANIDE -  (Prescribed by Other Provider) - 2 mg Tablet - 3
Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 8 Tablet(s) by mouth x 1
on
[**2132-12-10**], then 75mg qd
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] -  (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly
ESCITALOPRAM [LEXAPRO] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
EZETIMIBE-SIMVASTATIN [VYTORIN [**10/2102**]] -  (Prescribed by Other
Provider) - 10 mg-80 mg Tablet - 1 Tablet(s) by mouth qpm
GABAPENTIN -  (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [VICODIN] -  (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 2 Tablet(s) by mouth three
times
a day
HYDROCORTISONE [CORTEF] -  (Prescribed by Other Provider) - 20
mg
Tablet - 1 Tablet(s) by mouth  20mg in am and 5mg in am and 5mg
PM
INSULIN GLARGINE [LANTUS] -  (Prescribed by Other Provider) -
100
unit/mL Solution - 48 units am 15 units in PM
INSULIN LISPRO [HUMALOG] -  (Prescribed by Other Provider) - 100
unit/mL Solution - per sliding scale  under 100 22 24 20 101-150
26 26 22 151-200 28 28 24 201-[**Telephone/Fax (2) 24470**]51-300 34 32 28
301-350 35 34 30 351-400 37 36 32
ISOSORBIDE MONONITRATE -  (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE [SYNTHROID] -  (Prescribed by Other Provider) -
150
mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE [PROTONIX] -  (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a
day
PIOGLITAZONE [ACTOS] -  (Prescribed by Other Provider) - 30 mg
Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIR-81] -  (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth at bedtime as needed hold if diarrhea

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Nitrofurantoin Mono-Macro /
Cortisone / Levoxyl

PHYSICAL EXAM: Admission exam:
GENERAL: Obese elderly white woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Brother died from an MI at 50. Daughter had a stent at age 36.

SOCIAL HISTORY: She lives with her husband and daughter in a
house.  She has 4 children. She does not use any services
currently. She is independent in her ADL's but is known to have
a gait disorder and a history of falls in the past.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: None
Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other specified sites, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Acute respiratory failure,Cushing's syndrome,Other complications due to other cardiac device, implant, and graft,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Atrial fibrillation,Mononeuritis of unspecified site,Abnormal coagulation profile,Rash and other nonspecific skin eruption
Crnry athrscl natve vssl,AMI NEC, initial,Ac systolic hrt failure,Cardiogenic shock,Acute respiratry failure,Cushing's syndrome,Comp-oth cardiac device,Urin tract infection NOS,Surg compl-heart,Ac posthemorrhag anemia,Hematoma complic proc,Delirium d/t other cond,Hyperosmolality,Hypertension NOS,Hyperlipidemia NEC/NOS,Abn react-cardiac cath,Accid in resident instit,Hypothyroidism NOS,Klebsiella pneumoniae,Sec DM wo cmp nt st uncn,Adv eff corticosteroids,Atrial fibrillation,Mononeuritis NOS,Abnrml coagultion prfile,Nonspecif skin erupt NEC
Admission Date:  [**2132-12-11**]              Discharge Date:   [**2132-12-22**]

Date of Birth:  [**2057-11-26**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Nitrofurantoin Mono-Macro /
Cortisone / Levoxyl

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Elective PCI for three-vessel disease complicated by dissection
of Left Main

Major Surgical or Invasive Procedure:
cardiac catheterization x2 with stents to the right coronary
artery, Left main artery, Left anterior descending artery,
obtuse marginal artery.


History of Present Illness:
This 75 year old woman has a history of obesity, hypertension,
dyslipidemia, CAD and [**Location (un) 3484**] syndrome with longstanding
steroid use and subsequent development of DM. On [**2132-10-16**] she
underwent cardiac catheterization at [**Hospital3 2358**] [**2-26**] anginal sx
and an abnormal ETT. Angiography revealed three vessel disease
with a 50%stenosis of the RCA, 40% LM, 80-90% stenosis of her
OM1 and OM2, and a 90% stenosis of distal LAD. LVEF was noted at
60%.
.
She has since been evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from cardiac
surgery. Studies have revealed no usable lower extremity veins
for CABG. In addition, it is felt that Mrs.[**Known lastname 24469**] is quite
high
risk for sternal complications.  Plans were for PCI of the RCA,
OM1 and OM2 by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] with possible LIMA to LAD by
CTsurg at a later date.
.
During her catherization today her RCA was stented and while
trying to stent the OM's the Left Main was dissected then
stented. She denies any chest pain, and her EKG was not
concerning for evolving MI. Biomarkers were negative int he
immediate post-procedure period.

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- [**Location (un) **] disease s/p ablation of pituitary adenoma at [**Hospital1 2025**].
- Hip replacement for osteoarthritis.
- Obesity.
- Lower back pain.
- Status post right knee patella removal after motor vehicle
accident.
- History of left lower leg hematoma after a fall 3 years ago.
- Depression.
- Hypothyroidism.
- Deep vein thrombosis in left calf 3 years ago.
- Cataract in both eyes status post extraction.


Social History:
She lives with her husband and daughter in a
house.  She has 4 children. She does not use any services
currently. She is independent in her ADL's but is known to have
a gait disorder and a history of falls in the past.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: None

Family History:
Brother died from an MI at 50. Daughter had a stent at age 36.

Physical Exam:
Admission exam:
GENERAL: Obese elderly white woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple and obese. JVD not able to be assesed secondary to
body habitus
CARDIAC: S1 S2 faint SEM
LUNGS: Obese distant breath sounds. CTA BL
ABDOMEN: Obese NT +BS
EXTREMITIES: LE WWP Venous stasis dermatitis BL with exfoliative
scar on left anterior tibia. Left UE is without erythema but
mild non pitting edema. Right UE has large resolving hematoma
with pressure dressing in place.
PULSES:
Right: DP 2+ R not assesed [**2-26**] pressure dressing
Left: DP 2+ R 2+


Pertinent Results:
Admission labs:
[**2132-12-11**] 02:32PM   WBC-9.4 RBC-3.67* HGB-8.9* HCT-29.0* MCV-79*
MCH-24.3* MCHC-30.7* RDW-15.7*
[**2132-12-11**] 02:32PM   PT-23.8* PTT-55.5* INR(PT)-2.3*
[**2132-12-11**] 02:32PM   CALCIUM-8.8 PHOSPHATE-4.2 MAGNESIUM-2.4
[**2132-12-11**] 02:32PM   CK(CPK)-169
[**2132-12-11**] 02:32PM   CK-MB-13* MB INDX-7.7
[**2132-12-11**] 02:32PM   GLUCOSE-263* UREA N-45* CREAT-1.3* SODIUM-138
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-12
[**2132-12-11**] 11:25PM   CK-MB-62* MB INDX-8.4* cTropnT-2.74*
[**2132-12-11**] 11:25PM   LIPASE-26
[**2132-12-11**] 11:25PM   CK(CPK)-741* AMYLASE-31
.
Cardiac catheterization [**2132-12-14**]:

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LMCA, LAD, Lcx and RCA stents.
3. Significant OM1 lesion with flow.
4. STEMI lateral.
5. Moderate biventricular diastolic dysfunction.
6. Normal cardiac index.
7. Successful PCI of OM1 with BMSx2.
.
[**2132-12-15**] Echo:
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with hypokinesis of the basal inferior and inferolateral walls
and akinesis of the distal inferior, septal, and anterior walls.
The apex is mildly dyskinetic. The remaining segments contract
normally (LVEF = 30%). Right ventricular chamber size and free
wall motion are normal. Mild (1+) mitral regurgitation is seen.
There is an anterior space which most likely represents a
prominent fat pad.

Compared with the prior study (images reviewed) of [**2043-12-12**], the
basal inferolateral and inferior walls are now hypokinetic. The
anterior wall function and global systolic function are slightly
improved.
.
Labs on discharge:
[**2132-12-22**] 07:45AM BLOOD WBC-11.0 RBC-3.70* Hgb-9.7* Hct-30.2*
MCV-82 MCH-26.1* MCHC-31.9 RDW-17.0* Plt Ct-159
[**2132-12-22**] 07:45AM BLOOD Glucose-83 UreaN-34* Creat-1.2* Na-147*
K-3.6 Cl-108 HCO3-34* AnGap-9
[**2132-12-16**] 05:55AM BLOOD CK(CPK)-542*
[**2132-12-15**] 05:50AM BLOOD CK(CPK)-843*
[**2132-12-22**] 07:45AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.3

Brief Hospital Course:
75 YO woman with CAD SP PCI of RCA and OM's complicated by
dissection of left main with subsequent stenting and right
radial hematoma.
.
# CAD: No angina or ST elevations immediately following first
catheterization. CKMB is mildly elevated which could be evidence
of evolving MI. Will obtain echo and trend biomarkers. The
patient had to return to the cath lab for revision of original
procedure. On [**2132-12-12**], the patient's sedation was lifted and
she was extubated. She almost immediately [**Doctor First Name **] to complain of
chest pain. ECG showed ST elevations, and she was brought to
cath lab again. Selective coronary angiography of her right
dominant system revealed three-vessel CAD. The LMCA had patent
stents with persistent dissection outside stents. The LAD had
patent stents with diffuse distal disease. The LCx had patent
stents; the OM1 had reopened since prior cath had had a 95%
proximal stenosis with associated limited dissection from prior.
The RCA had patent stents with a 95% PDA stenosis present on
prior
films. Successful PTCA and stenting of large OM1 with two
overlapping 2.25x12 MiniVision bare metal stents postdilated to
2.5mm. The [**Hospital 228**] medical management included aspirin,
Plavix, simvastatin, metoprolol and ezetimibe. She will be on
Plavix for the rest of her life. Do not stop Plavix without
first speaking to Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] at [**Hospital1 18**]. Her peak CK was 4332
in the setting of extensive chest pain and manipulation of
coronary arteries. Her creatinine increased to 1.3 after
contrast load, currently at 1.2.
.
# Acute systolic Dysfunction: The echocardiogram of [**2132-12-15**]
showed reduced LVEF of 30% in the setting of STEMI. Although
cardiac catheterization showed high filling pressures, she has
appeared euvolemic with no signs of fluid overload and has not
required standing diuretics. Her Lisinopril was decreased to 5
mg daily. she should have daily weights and close monitoring of
her fluid status.
.
# Atrial Fibrillation: Noted in the setting of MI. Currently in
AF with frequent bradycardia at night, she is asymptomatic with
these episodes. She is on very low dose metoprolol for MI
prevention  but this can be discontinued if HR cont to be an
issue. Extensive discussion regarding coumadin. Decision made to
treat with ASA and Plavix only given hx of falls and likelihood
that EF will increase in the long term.
.
# Radial Hematoma: Resolving. No symptoms of compartment
syndrome (pain, cap refill, pulses) were noted.
.
# [**Location (un) 3484**] disease: Patient was cotinued on her home dose of
25mg of cortisef in the AM and 5mg in PM. Given the stressors,
however, of her cardiac events, dosing was increased to 100mg.
The Endocrine team was consulted, and the patient was placed on
100mg hydrocortisone IV three times a day. As her condition
stabilized, a taper was started and she is now currently back on
her home Cortisone [**Location (un) 4319**]. She will need to have stress dose
steriods for any medical procedures. Her endocrinologist at
[**Last Name (un) **] should be contact[**Name (NI) **].
.
# DM: The patient was kept on an insulin sliding scale. Her
blood sugars were quite high with stress dose steriods but are
now normalizing on a slightly decreased lantus dose.

# Depression: Continued home escitalopram.
.
# Hypothyroidism: Patient was started on home dosing of
synthroid. Given that she was intubated on multiple occasions,
however, she instead received IV levothyroxine at the same
approximate dose for several days, now back on PO dosing.
.
# Hypertension: SBP was somewhat low so her Imdur and Norvasc
was not restarted and her Lisinopril was decreased to 5 mg
daily.
.
# Dyslipidemia: Continued home dosing of simvastatin and
ezetimibe.
.
# Neuropathy: Continue neurontin but dose [**Month (only) **] to 300 mg daily.
PCP would like to d/c entirely if possible. Vicodin was
restarted at discharge at home dose per family. This medicine is
the only one that seems to alleviate pain.
.
# Delerium: Noted after extubation and thought to be related to
sedation, ICU stay and UTI. Her memory is mildly impaired at
baseline. Currently improving on scheduled Seroquel dosing in
the evening. Would recommend freq reorientation, avoidance of
benzos (tiny home dose of Aprazolam d/c'ed) and night time
interruptions. Assume that pt will return to her home where she
lives with her daughter and husband.
.
# Papillomatous rash of groin: Dermatology consulted and rec
miconazole powder. Currently improving.


Medications on Admission:
ALPRAZOLAM -  (Prescribed by Other Provider) - 0.5 mg Tablet -
[**1-28**] Tablet(s) by mouth once a day
AMLODIPINE [NORVASC] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
BUMETANIDE -  (Prescribed by Other Provider) - 2 mg Tablet - 3
Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 8 Tablet(s) by mouth x 1
on
[**2132-12-10**], then 75mg qd
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] -  (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly
ESCITALOPRAM [LEXAPRO] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
EZETIMIBE-SIMVASTATIN [VYTORIN [**10/2102**]] -  (Prescribed by Other
Provider) - 10 mg-80 mg Tablet - 1 Tablet(s) by mouth qpm
GABAPENTIN -  (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [VICODIN] -  (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 2 Tablet(s) by mouth three
times
a day
HYDROCORTISONE [CORTEF] -  (Prescribed by Other Provider) - 20
mg
Tablet - 1 Tablet(s) by mouth  20mg in am and 5mg in am and 5mg
PM
INSULIN GLARGINE [LANTUS] -  (Prescribed by Other Provider) -
100
unit/mL Solution - 48 units am 15 units in PM
INSULIN LISPRO [HUMALOG] -  (Prescribed by Other Provider) - 100
unit/mL Solution - per sliding scale  under 100 22 24 20 101-150
26 26 22 151-200 28 28 24 201-[**Telephone/Fax (2) 24470**]51-300 34 32 28
301-350 35 34 30 351-400 37 36 32
ISOSORBIDE MONONITRATE -  (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE [SYNTHROID] -  (Prescribed by Other Provider) -
150
mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE [PROTONIX] -  (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a
day
PIOGLITAZONE [ACTOS] -  (Prescribed by Other Provider) - 30 mg
Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIR-81] -  (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth at bedtime as needed hold if diarrhea


Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop taking this medicine unless Dr. [**Last Name (STitle) 911**] tells
you to. .
2. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. bumetanide 2 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO once a week.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 24H
(Every 24 Hours).
10. hydrocodone-acetaminophen 7.5-650 mg Tablet Sig: One (1)
Tablet PO three times a day: Home dose that works well per
family.
11. Cortef 20 mg Tablet Sig: One (1) Tablet PO qAM ().
12. Cortef 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)): Take with 20 mg tablet for total of 25 mg in
the morning.
13. Cortef 5 mg Tablet Sig: One (1) Tablet PO qPM ().
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical
three times a day as needed for [**Female First Name (un) **].
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Hold for diarrhea.
17. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO daily ().
18. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold SBP < 100.
19. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
20. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
21. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4PM ().
22. quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q10PM ().
23. insulin glargine 100 unit/mL Solution Sig: Twenty Six (26)
units Subcutaneous once a day: give before breakfast.
24. Humalog 100 unit/mL Solution Sig: per fixed dose and sliding
scale units Subcutaneous four times a day: see attached scale.
25. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Coronary artery disease
Hypertension
Diabetes [**First Name9 (NamePattern2) **]
[**Location (un) 3484**] syndrome
Hypernatremia
Delerium
Acute Systolic dysfunction


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


Discharge Instructions:
You had chest pain and a heart attack. There were multiple
arteries that were blocked and over the course of 3 cardiac
catheterizations, we were able to open them. You will need to
take Plavix every day for the rest of your life. Do no stop
taking Plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 911**] tells you it is
OK. We also changed some of your heart medicines to help your
heart pump better. You were seen by [**Last Name (un) **] doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **]
were here to manage your diabetes and Cushings disorder.
Medication changes:
1. Stop taking Aprazolam, Norvasc and Imdur
2. Start taking Miconazole powder in your groin area to treat a
yeast infection
3. Start taking Metoprolol to help your heart recover from the
heart attack
4. Start taking Quetiapine to help keep you calm in the evening
5. Increase aspirin to 325 mg daily for at least one month
6. Decrease Gabapentin to 300 mg daily because of your kidney
Function
7. Decrease Lisinopril to 5mg daily because of your kidney
function
8. Decrease your Glargine and Humalog per the sliding scale.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 911**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.

Followup Instructions:
Department: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD
When: WEDNESDAY [**2133-6-3**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14647**], MD [**Telephone/Fax (1) 11262**]
Building: [**Last Name (NamePattern1) 14648**] ([**Location (un) 86**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: None

Department: CARDIAC SERVICES
When: WEDNESDAY [**2133-2-4**] at 1:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Last Name (LF) 14591**], [**First Name3 (LF) 14590**] N. MD
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appt:  We are working on a follow up appt for you within the
next two weeks.  The office will call you at home with an appt.
If you dont hear from them in 48 hours, please call office
directly to book.



Completed by:[**2132-12-22**]
{"Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other specified sites, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Acute respiratory failure,Cushing's syndrome,Other complications due to other cardiac device, implant, and graft,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Atrial fibrillation,Mononeuritis of unspecified site,Abnormal coagulation profile,Rash and other nonspecific skin eruption"}


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: Elective PCI for three-vessel disease complicated by dissection
of Left Main

PRESENT ILLNESS: This 75 year old woman has a history of obesity, hypertension,
dyslipidemia, CAD and [**Location (un) 3484**] syndrome with longstanding
steroid use and subsequent development of DM. On [**2132-10-16**] she
underwent cardiac catheterization at [**Hospital3 2358**] [**2-26**] anginal sx
and an abnormal ETT. Angiography revealed three vessel disease
with a 50%stenosis of the RCA, 40% LM, 80-90% stenosis of her
OM1 and OM2, and a 90% stenosis of distal LAD. LVEF was noted at
60%.
.
She has since been evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from cardiac
surgery. Studies have revealed no usable lower extremity veins
for CABG. In addition, it is felt that Mrs.[**Known lastname 24469**] is quite
high
risk for sternal complications.  Plans were for PCI of the RCA,
OM1 and OM2 by Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] with possible LIMA to LAD by
CTsurg at a later date.
.
During her catherization today her RCA was stented and while
trying to stent the OM's the Left Main was dissected then
stented. She denies any chest pain, and her EKG was not
concerning for evolving MI. Biomarkers were negative int he
immediate post-procedure period.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- [**Location (un) **] disease s/p ablation of pituitary adenoma at [**Hospital1 2025**].
- Hip replacement for osteoarthritis.
- Obesity.
- Lower back pain.
- Status post right knee patella removal after motor vehicle
accident.
- History of left lower leg hematoma after a fall 3 years ago.
- Depression.
- Hypothyroidism.
- Deep vein thrombosis in left calf 3 years ago.
- Cataract in both eyes status post extraction.

MEDICATION ON ADMISSION: ALPRAZOLAM -  (Prescribed by Other Provider) - 0.5 mg Tablet -
[**1-28**] Tablet(s) by mouth once a day
AMLODIPINE [NORVASC] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
BUMETANIDE -  (Prescribed by Other Provider) - 2 mg Tablet - 3
Tablet(s) by mouth once a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 8 Tablet(s) by mouth x 1
on
[**2132-12-10**], then 75mg qd
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] -  (Prescribed by Other
Provider) - 50,000 unit Capsule - 1 Capsule(s) by mouth weekly
ESCITALOPRAM [LEXAPRO] -  (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
EZETIMIBE-SIMVASTATIN [VYTORIN [**10/2102**]] -  (Prescribed by Other
Provider) - 10 mg-80 mg Tablet - 1 Tablet(s) by mouth qpm
GABAPENTIN -  (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth twice a day
HYDROCODONE-ACETAMINOPHEN [VICODIN] -  (Prescribed by Other
Provider) - 5 mg-500 mg Tablet - 2 Tablet(s) by mouth three
times
a day
HYDROCORTISONE [CORTEF] -  (Prescribed by Other Provider) - 20
mg
Tablet - 1 Tablet(s) by mouth  20mg in am and 5mg in am and 5mg
PM
INSULIN GLARGINE [LANTUS] -  (Prescribed by Other Provider) -
100
unit/mL Solution - 48 units am 15 units in PM
INSULIN LISPRO [HUMALOG] -  (Prescribed by Other Provider) - 100
unit/mL Solution - per sliding scale  under 100 22 24 20 101-150
26 26 22 151-200 28 28 24 201-[**Telephone/Fax (2) 24470**]51-300 34 32 28
301-350 35 34 30 351-400 37 36 32
ISOSORBIDE MONONITRATE -  (Prescribed by Other Provider) - 30 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day
LEVOTHYROXINE [SYNTHROID] -  (Prescribed by Other Provider) -
150
mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
PANTOPRAZOLE [PROTONIX] -  (Prescribed by Other Provider) - 40
mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a
day
PIOGLITAZONE [ACTOS] -  (Prescribed by Other Provider) - 30 mg
Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN [ASPIR-81] -  (Prescribed by Other Provider) - 81 mg
Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
SENNA -  (Prescribed by Other Provider) - 8.6 mg Capsule - 1
Capsule(s) by mouth at bedtime as needed hold if diarrhea

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Nitrofurantoin Mono-Macro /
Cortisone / Levoxyl

PHYSICAL EXAM: Admission exam:
GENERAL: Obese elderly white woman in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Brother died from an MI at 50. Daughter had a stent at age 36.

SOCIAL HISTORY: She lives with her husband and daughter in a
house.  She has 4 children. She does not use any services
currently. She is independent in her ADL's but is known to have
a gait disorder and a history of falls in the past.
-Tobacco history: Never
-ETOH: None
-Illicit drugs: None 

### Response:
{"Coronary atherosclerosis of native coronary artery,Acute myocardial infarction of other specified sites, initial episode of care,Acute systolic heart failure,Cardiogenic shock,Acute respiratory failure,Cushing's syndrome,Other complications due to other cardiac device, implant, and graft,Urinary tract infection, site not specified,Cardiac complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematoma complicating a procedure,Delirium due to conditions classified elsewhere,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified acquired hypothyroidism,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Atrial fibrillation,Mononeuritis of unspecified site,Abnormal coagulation profile,Rash and other nonspecific skin eruption"}
