CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 82-year-old male patient with a past medical history of
hypertension and a renal mass presented with chest pain found to
have NSTEMI, now s/p BMS stent in [**Hospital 54969**] transferred to CCU after
emesis with Hct drop.
.
Patient previously underwent preoperative evaluation for his
renal mass in [**2131-12-31**] which included a nuclear stress
test. He was found to have a large moderately severe reversible
perfusion defect involving the mid to distal anterior wall,
extending into the septum and also a moderately severe partially
reversible partially fixed defect involving the entire apex. His
LVEF was 56%. The exercise portion demonstrated ischemic EKG
changes and chest pain. He was scheduled for a cardiac
catheterization at the [**Hospital1 **] with Dr. [**Last Name (STitle) 14522**].
.
However, on [**2132-2-18**] patient experienced chest discomfort while
at the [**Company 3596**]. Patient was doing his routine exercise of walking
around the track when he experienced 6/10 chest pain which was
localized to the right side and radiated to his back. Pain was
described as "tightening" and was associated with nausea. No
vomiting, no diaphoresis, no associated shortness of breath.
Pain became maximal at [**2133-8-6**]. Patient was taken to the [**Hospital1 392**]
ER where he was given ASA, and 2 sublingual nitroglycerin.
Patient reports chest pain improvement to 4=>2=> 0/10 after
sublingual nitroglycerin. Patient was also given Lovenox and
12.5 of lopressor and admitted to the hospital. His initial
troponin was < 0.01. He was admitted to ICU and his troponin on
day of admission was 1.9 with a CPK of 85. He has had no further
episoded of chest discomfort.
.
He was transferred to the [**Hospital1 18**] on [**2132-2-19**], underwent a cath on
[**2132-2-20**] that showed a 90% stenosis in the LAD but stenting was
unsuccessful due to inability to engage the left main with any
guide. He underwent a repeat cath on [**2132-2-21**] with left brachial
arterial insertion and this time received a BMS stent in his
LAD. Post-cath course was notable for pseudoaneurysm in his
brachial site requiring thrombin injection by IR on [**2132-2-22**]. In
the afternoon of [**2132-2-22**] he had a small, prune-colored emesis
that was guaiac negative. His Hct dropped from 30 to 26 then 22
despite 1 unit of pRBC. He was transferred to the CCU for
further management.
.
On arrival to the CCU, patient was clinically stable, with no
more emesis.
.
Review of systems postive for worsening dyspnea on exertion.
Patient describes shortness of breath when exercising at the
[**Company 3596**]. patient states that when he walks around the track gets
SOB and + angina similar to episode described above. In
addition, patient endorses + presyncopal feeling with these
episodes but denies any exertional syncope.
.

MEDICAL HISTORY: hypertension
Hematuria - ?prostatitis
Glaucoma left eye
left cRenal mass
Colon adenoma
CAD - diagnosed by stress test
? Depression
Elevated PSA
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: OUTPATIENT MEDICATIONS:
Azopt 1% OS TID
Prozac 20 mg PO daily
HCTZ 12.5 mg Po daily
Dorzolamide 1% TID
Timolol 1 drop L eye daily
.
Medications recieved at OSH:
Lovenox
Predisone
Benadryl
Zantac
Metoprolol

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: VS - Temp 97.2, BP 167/90, P 64, R 22, 100% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. + anisocoria. EOMI. Conjunctiva
non-injected, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
Neck: Supple with JVP to clavicle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds throughout. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas

FAMILY HISTORY: heart attack in patient's father at age 60. [**Name (NI) **] father
died of aortic aneurysm at age 68.

SOCIAL HISTORY: Pt quit smoking 20 years ago used to smoek 3-4 packs per day x
20 years. There is no history of alcohol abuse.
Subendocardial infarction, initial episode of care,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematemesis,Hematoma complicating a procedure,Aneurysm of artery of upper extremity,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortic valve disorders,Chronic kidney disease, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Esophagitis, unspecified,Depressive disorder, not elsewhere classified,Unspecified glaucoma,Elevated prostate specific antigen [PSA],Personal history of colonic polyps,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Subendo infarct, initial,Surg comp-peri vasc syst,Ac posthemorrhag anemia,Hematemesis,Hematoma complic proc,Upper extremity aneurysm,Crnry athrscl natve vssl,Renal & ureteral dis NOS,Hy kid NOS w cr kid I-IV,Aortic valve disorder,Chronic kidney dis NOS,Gstr/ddnts NOS w/o hmrhg,Esophagitis, unspecified,Depressive disorder NEC,Glaucoma NOS,Elvtd prstate spcf antgn,Prsnl hst colonic polyps,Abn react-cardiac cath
Admission Date:  [**2132-2-19**]              Discharge Date:   [**2132-2-29**]

Date of Birth:  [**2050-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine; Iodine Containing

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Cardiac catherization x2 (one via groin, the other via left arm)
Blood transfusion


History of Present Illness:
82-year-old male patient with a past medical history of
hypertension and a renal mass presented with chest pain found to
have NSTEMI, now s/p BMS stent in [**Hospital 54969**] transferred to CCU after
emesis with Hct drop.
.
Patient previously underwent preoperative evaluation for his
renal mass in [**2131-12-31**] which included a nuclear stress
test. He was found to have a large moderately severe reversible
perfusion defect involving the mid to distal anterior wall,
extending into the septum and also a moderately severe partially
reversible partially fixed defect involving the entire apex. His
LVEF was 56%. The exercise portion demonstrated ischemic EKG
changes and chest pain. He was scheduled for a cardiac
catheterization at the [**Hospital1 **] with Dr. [**Last Name (STitle) 14522**].
.
However, on [**2132-2-18**] patient experienced chest discomfort while
at the [**Company 3596**]. Patient was doing his routine exercise of walking
around the track when he experienced 6/10 chest pain which was
localized to the right side and radiated to his back. Pain was
described as "tightening" and was associated with nausea. No
vomiting, no diaphoresis, no associated shortness of breath.
Pain became maximal at [**2133-8-6**]. Patient was taken to the [**Hospital1 392**]
ER where he was given ASA, and 2 sublingual nitroglycerin.
Patient reports chest pain improvement to 4=>2=> 0/10 after
sublingual nitroglycerin. Patient was also given Lovenox and
12.5 of lopressor and admitted to the hospital. His initial
troponin was < 0.01. He was admitted to ICU and his troponin on
day of admission was 1.9 with a CPK of 85. He has had no further
episoded of chest discomfort.
.
He was transferred to the [**Hospital1 18**] on [**2132-2-19**], underwent a cath on
[**2132-2-20**] that showed a 90% stenosis in the LAD but stenting was
unsuccessful due to inability to engage the left main with any
guide. He underwent a repeat cath on [**2132-2-21**] with left brachial
arterial insertion and this time received a BMS stent in his
LAD. Post-cath course was notable for pseudoaneurysm in his
brachial site requiring thrombin injection by IR on [**2132-2-22**]. In
the afternoon of [**2132-2-22**] he had a small, prune-colored emesis
that was guaiac negative. His Hct dropped from 30 to 26 then 22
despite 1 unit of pRBC. He was transferred to the CCU for
further management.
.
On arrival to the CCU, patient was clinically stable, with no
more emesis.
.
Review of systems postive for worsening dyspnea on exertion.
Patient describes shortness of breath when exercising at the
[**Company 3596**]. patient states that when he walks around the track gets
SOB and + angina similar to episode described above. In
addition, patient endorses + presyncopal feeling with these
episodes but denies any exertional syncope.
.


Past Medical History:
hypertension
Hematuria - ?prostatitis
Glaucoma left eye
left cRenal mass
Colon adenoma
CAD - diagnosed by stress test
? Depression
Elevated PSA
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +Hypertension



Social History:
Pt quit smoking 20 years ago used to smoek 3-4 packs per day x
20 years. There is no history of alcohol abuse.

Family History:
heart attack in patient's father at age 60. [**Name (NI) **] father
died of aortic aneurysm at age 68.

Physical Exam:
VS - Temp 97.2, BP 167/90, P 64, R 22, 100% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. + anisocoria. EOMI. Conjunctiva
non-injected, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
Neck: Supple with JVP to clavicle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds throughout. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas


Pertinent Results:
[**2132-2-20**] 05:45AM BLOOD Hct-29.9*
[**2132-2-22**] 10:13PM BLOOD WBC-10.7 RBC-3.15* Hgb-9.3* Hct-26.6*
MCV-85 MCH-29.4 MCHC-34.7 RDW-15.0 Plt Ct-242
[**2132-2-29**] 07:20AM BLOOD Hct-28.7*
[**2132-2-24**] 07:35AM BLOOD Neuts-68.8 Lymphs-17.5* Monos-9.4
Eos-4.1* Baso-0.2
[**2132-2-20**] 03:00AM BLOOD PTT-68.0*
[**2132-2-20**] 05:45AM BLOOD PT-13.3 INR(PT)-1.1
[**2132-2-20**] 05:45AM BLOOD Glucose-127* UreaN-36* Creat-1.4* Na-139
K-4.5 Cl-102 HCO3-28 AnGap-14
[**2132-2-29**] 07:20AM BLOOD Glucose-96 UreaN-27* Creat-1.4* Na-140
K-5.0 Cl-105 HCO3-31 AnGap-9
[**2132-2-19**] 09:31PM BLOOD CK(CPK)-60
[**2132-2-20**] 05:45AM BLOOD ALT-16 AST-27 LD(LDH)-159 CK(CPK)-50
AlkPhos-57 TotBili-0.4
[**2132-2-19**] 09:31PM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2132-2-22**] 10:13PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2132-2-23**] 05:16AM BLOOD CK-MB-NotDone cTropnT-0.21*
[**2132-2-20**] 05:45AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3 Cholest-185
[**2132-2-21**] 07:35PM BLOOD Iron-168*
[**2132-2-29**] 07:20AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.2
[**2132-2-21**] 07:35PM BLOOD calTIBC-264 VitB12-1180* Folate-GREATER
TH Ferritn-42 TRF-203
[**2132-2-20**] 05:45AM BLOOD Triglyc-34 HDL-60 CHOL/HD-3.1 LDLcalc-118
.
Echo [**2132-2-21**]- The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Transmitral Doppler and tissue
velocity imaging are consistent with Grade I (mild) LV diastolic
dysfunction. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. Moderate (2+) aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
.
EGD [**2132-2-25**] Impression: Erythema and congestion in the antrum
compatible with gastritis Esophagitis in the lower third of the
esophagus and gastroesophageal junction. Hiatal hernia.
Otherwise normal EGD to third part of the duodenum
Recommendations: Biopsies not performed as patient is on Plavix.
Continue PPI b.i.d. indefinitely. Follow-up with primary care
physician
.
IMPRESSION: Normal biventricular regional and global systolic
function. Moderately dilated ascending aorta and mildly dilated
aortic root with moderate aortic regurgitation.
.
Cardiac catherization [**2132-2-20**]- COMMENTS:
1.  Coronary angiography of this right dominant system revealed
single vessel CAD.  The LMCA, LCx, and RCA had no
angiographically apparent obstructive CAD.  The LAD had a 99%
proximal stenosis.
2.  Hemodynamic evaluation revealed normal right sided filling
pressures (RVEDP 7 mm Hg) and elevated left sided filling
pressures (LVEDP 17 mm Hg).  Mean PCWP was 11 mm Hg.  Systemic
arterial pressures were elevated with aortic systolic pressure
of 151 mm Hg.  Cardiac index was preserved at 2.8 l/min/m2.
3.  Left ventriculography was not performed.
4. Attempt at PCI of the LCX was unsuccessful due to the
inability to
engage the left main coronary artery with a JL 4, JL 4.5, JL 5,
XB LAD 3.5, XB 4.0, XB 4.5, [**Doctor Last Name **] 2m [**Doctor Last Name **] 3 and a MPA guide.
Eventually a diagnostic JL5 reengaged the artery and the LCX was
wired with a prowater wire. We attempted to exchange the JL 5
for a guide but lost wire position during the exchange. After 60
minutes of fluro time we elected to terminate the procedure and
plan to bring the patient back for a radial approach.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Systemic arterial hypertension.
4. Unsuccessful guide engagement of the LMCA.
.
Repeat ultrasound of left upper extremity - findings: the left
brachial artery widely patent with normal flow, pseudoanuersym
is thrombosed without flow. successful injection which no longer
contains flow. native brachial artery with normal flow.


Brief Hospital Course:
82 year old male with PMHx of HTN, CAD, renal mass presents with
exertional chest pain. Patient with history of positive imaging
stress test who was planning to undergo routine catherization
went to cardiac catherization x2 with intervention to LAD.
Hospital course complicated by pseudoaneurysm at site of left
arm catherization as well as upper GI bleed.
.
#. CAD/ upper extremity hematoma - patient with ischemia at near
maximal workload in the distribution of the LAD with qualitative
transient ischemic dilatation on stress with imaging from
12/[**2131**]. EKG from admission with chest pain with
pseudonormalization of T waves in anterior distribution of V2-V4
which suggests anterior wall ischemia. In addition, chest pain
is classic anginal chest pain as it occurs with exertion,
improves with rest, relieved by nitroglycerin. Patient underwent
initial cardiac catherization which demonstrated LAD lesion with
failed attempt with intervention. Repeat catherization via left
arm with LAD stent complicated by psuedoaneurysm requiring
thrombin injection. Lipids on admission with HDL 60, LDL 118,
triglycerides 34. Repeat upper extremity ultrasound demonstrates
normal brachial artery flow with complete occlusion of the
pseudoaneursym that was there before. Telemetry demonstrates 7
PVCs. Patient was started on high dose statin, aspirin, and beta
blocker. LFTs on admission WNL. Beta blocker initially held in
the setting of GI bleed restarted on discharge. Patient also
started on plavix. Patient will need to be on aspirin/plavix for
3 month minimum on discharge.
.
# Hct drop and emesis: likely upper GI bleed. Patient underwent
upper endoscopy on [**2132-2-25**] which demonstrated esophagitis and
gastritis. CT abd/pelvis showed absence of RP bleed. Other
sources of blood loss include Hct drop include hematoma in L
arm.  Patient on PPi [**Hospital1 **] and crits measured [**Hospital1 **] with transfusion
for crit less than 28. Patient initially transferred to CCU in
the setting of falling crit with transfusions. Patient started
on PO PPi [**Hospital1 **] and was transfused several units. EGD demonstrated
severe esophagitis, gastritis without continued bleed.
colonscopy demonstrated diverticulosis without any active
bleeding.
.
#. Pump - patient with echo from stress which demonstrate EF
56%. Clinically no evidence of heart failure with absence of
lower extremity edema, clear lungs, and no elevation of JVP.
Repeat echo demonstrates normal biventricular regional and
global systolic function. Moderately dilated ascending aorta and
mildly dilated aortic root with moderate aortic regurgitation.
Patient started on aspirin, statin, plavix on admission.
.
#. Rhythm - patient in NSR with normal intervals. Repeat EKG
from [**2132-2-22**] demonstrates Sinus rhythm. The P-R interval is
0.18. The Q-T interval is prolonged. Anterior, anterolateral and
lateral ST-T wave changes are consistent with ischemia or
myocardial infarction. Compared to the previous tracing  of
[**2132-2-21**] there is no significant change. Patient started on beta
blocker as above.
.
#. HTN: Pt currently controlled. 117/76 on transfer. Patient on
beta blocker and HCTZ as an outpatient which were continued.
.
# Mild to moderate aortic regurgitation - patient with mild to
moderate aortic regurgitation. Patient on low dose beta blocker
because of CAD.  Would consider addition of ACEi for afterload
reduction as an outpatient.  Patient needs routine outpatient
echo follow-up as per primary cardiologist
.
# Chronic renal failure - patient with Cr 1.4 which appears to
be at his baseline. Patient recieved routine post catherization
hydration. Medications were renally dosed and nephrotoxins
avoided.
.
#. Renal Mass - as per the radiology report appears likely
malignancy. Patient is undergoing pre-operative clearance for
surgery. Also patient noted to have elevated PSA from OSH to 21.
In addition, patient had bare metal stent placed so that patient
will not have to be on aspirin/plavix combination as long.
.
# Glaucoma - continue home medications
.
# Depression - continue outpatient fluoxetine
.
#. Access: 2 peripheral IVs at all time
.
#. PPx:  subQ heparin, colace, senna, [**Hospital1 **] PPi PO
.
#. Code:  Full Code


Medications on Admission:
OUTPATIENT MEDICATIONS:
Azopt 1% OS TID
Prozac 20 mg PO daily
HCTZ 12.5 mg Po daily
Dorzolamide 1% TID
Timolol 1 drop L eye daily
.
Medications recieved at OSH:
Lovenox
Predisone
Benadryl
Zantac
Metoprolol

ALLERGIES:
Iodine dye-hives


Discharge Medications:
1. Azopt 1 % Drops, Suspension Sig: One (1) drop Ophthalmic
three times a day: OS.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Dorzolamide 2 % Drops Sig: One (1) drop Ophthalmic three
times a day.
5. Timolol 0.25 % Drops Ophthalmic
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*10 Tablet, Sublingual(s)* Refills:*0*
9. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
12. Ecotrin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
primary: chest pain, NSTEMI, CAD with LAD stent placement, upper
GI bleed
.
Secondary:
HTN
glaucoma
renal mass
colon adenoma
? Depression
h/o elevated PSA
esophagitis
gastritis

Discharge Condition:
afebrile, vital signs stable

Discharge Instructions:
You were admitted to the hospital for cardiac catherization. You
underwent two cardiac catherizations and had a stent placed to
the LAD during the second catherization. Your cardiac
catherization was complicated by a left arm hematoma which
resulted in a hematocrit drop and subsequent need for several
blood transfusions.  Prior to catherization you were treated
with IV heparin as well as aspirin, plavix, statin and beta
blocker.
.
Your hospitalization course was complicated by an upper GI bleed
for which you underwent endoscopy which demonstrated erosive
esophagitis as well as gastritis. You were transfused several
units of blood with this blood loss as well as started on a PPi
[**Hospital1 **]. In addition, you underwent colonoscopy which demonstrated
no evidence of active bleed and only evidence of diverticulosis.
.
You are being discharged home on multiple new medications given
your coronary artery disease:
1) You were started on metoprolol (beta blocker) for your
coronary artery disease
2) You were started on a atorvastatin for your coronary artery
disease
3) You were started on Plavix for your coronary artery disease
4) You were started on a PPi for your GI bleed
5) You were started on full dose enteric coated aspirin
.
You were continued on the remainder of your outpatient
medications.
.
You should follow up with Dr. [**Last Name (STitle) **] within 2 weeks of discharge.
Please call at your convenience to arrange follow-up. In
addition, you should follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 98645**] within
2 weeks.
.
You should return to the ED if you experience any chest pain,
shortness of breath, or worsening pain at your catherization
site. It has been a pleasure taking care of you at [**Hospital1 **].

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. You can reach him at
([**Telephone/Fax (1) 5455**] to schedule at your convenience.
In addition, please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 98645**] within 2
weeks. please call ([**Telephone/Fax (1) 98646**] to schedule.
.
We have schedule you follow up appointment with gastroenterology
listed below:
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2132-4-21**] 7:30
Provider: [**First Name11 (Name Pattern1) 870**] [**Last Name (NamePattern4) 80703**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2132-4-21**] 7:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 7960**]  Follow-up appointment
should be in 2 weeks
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 35985**]  Follow-up appointment
should be in 2 weeks



Completed by:[**2132-3-2**]
{'Subendocardial infarction, initial episode of care,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematemesis,Hematoma complicating a procedure,Aneurysm of artery of upper extremity,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortic valve disorders,Chronic kidney disease, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Esophagitis, unspecified,Depressive disorder, not elsewhere classified,Unspecified glaucoma,Elevated prostate specific antigen [PSA],Personal history of colonic polyps,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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



### Clinical text :
CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 82-year-old male patient with a past medical history of
hypertension and a renal mass presented with chest pain found to
have NSTEMI, now s/p BMS stent in [**Hospital 54969**] transferred to CCU after
emesis with Hct drop.
.
Patient previously underwent preoperative evaluation for his
renal mass in [**2131-12-31**] which included a nuclear stress
test. He was found to have a large moderately severe reversible
perfusion defect involving the mid to distal anterior wall,
extending into the septum and also a moderately severe partially
reversible partially fixed defect involving the entire apex. His
LVEF was 56%. The exercise portion demonstrated ischemic EKG
changes and chest pain. He was scheduled for a cardiac
catheterization at the [**Hospital1 **] with Dr. [**Last Name (STitle) 14522**].
.
However, on [**2132-2-18**] patient experienced chest discomfort while
at the [**Company 3596**]. Patient was doing his routine exercise of walking
around the track when he experienced 6/10 chest pain which was
localized to the right side and radiated to his back. Pain was
described as "tightening" and was associated with nausea. No
vomiting, no diaphoresis, no associated shortness of breath.
Pain became maximal at [**2133-8-6**]. Patient was taken to the [**Hospital1 392**]
ER where he was given ASA, and 2 sublingual nitroglycerin.
Patient reports chest pain improvement to 4=>2=> 0/10 after
sublingual nitroglycerin. Patient was also given Lovenox and
12.5 of lopressor and admitted to the hospital. His initial
troponin was < 0.01. He was admitted to ICU and his troponin on
day of admission was 1.9 with a CPK of 85. He has had no further
episoded of chest discomfort.
.
He was transferred to the [**Hospital1 18**] on [**2132-2-19**], underwent a cath on
[**2132-2-20**] that showed a 90% stenosis in the LAD but stenting was
unsuccessful due to inability to engage the left main with any
guide. He underwent a repeat cath on [**2132-2-21**] with left brachial
arterial insertion and this time received a BMS stent in his
LAD. Post-cath course was notable for pseudoaneurysm in his
brachial site requiring thrombin injection by IR on [**2132-2-22**]. In
the afternoon of [**2132-2-22**] he had a small, prune-colored emesis
that was guaiac negative. His Hct dropped from 30 to 26 then 22
despite 1 unit of pRBC. He was transferred to the CCU for
further management.
.
On arrival to the CCU, patient was clinically stable, with no
more emesis.
.
Review of systems postive for worsening dyspnea on exertion.
Patient describes shortness of breath when exercising at the
[**Company 3596**]. patient states that when he walks around the track gets
SOB and + angina similar to episode described above. In
addition, patient endorses + presyncopal feeling with these
episodes but denies any exertional syncope.
.

MEDICAL HISTORY: hypertension
Hematuria - ?prostatitis
Glaucoma left eye
left cRenal mass
Colon adenoma
CAD - diagnosed by stress test
? Depression
Elevated PSA
Cardiac Risk Factors: - Diabetes, - Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: OUTPATIENT MEDICATIONS:
Azopt 1% OS TID
Prozac 20 mg PO daily
HCTZ 12.5 mg Po daily
Dorzolamide 1% TID
Timolol 1 drop L eye daily
.
Medications recieved at OSH:
Lovenox
Predisone
Benadryl
Zantac
Metoprolol

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: VS - Temp 97.2, BP 167/90, P 64, R 22, 100% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. + anisocoria. EOMI. Conjunctiva
non-injected, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
Neck: Supple with JVP to clavicle.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. distant heart sounds. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis.
Decreased breath sounds throughout. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas

FAMILY HISTORY: heart attack in patient's father at age 60. [**Name (NI) **] father
died of aortic aneurysm at age 68.

SOCIAL HISTORY: Pt quit smoking 20 years ago used to smoek 3-4 packs per day x
20 years. There is no history of alcohol abuse. 

### Response:
{'Subendocardial infarction, initial episode of care,Peripheral vascular complications, not elsewhere classified,Acute posthemorrhagic anemia,Hematemesis,Hematoma complicating a procedure,Aneurysm of artery of upper extremity,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortic valve disorders,Chronic kidney disease, unspecified,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Esophagitis, unspecified,Depressive disorder, not elsewhere classified,Unspecified glaucoma,Elevated prostate specific antigen [PSA],Personal history of colonic polyps,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
