CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: Ms. [**Known lastname 13469**] is a 61 year-old woman with a history of coronary
artery disease with CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA) with
known occluded vein grafts and recent admission with stenting to
her LAD who presents with chest pain.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:
(-) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG:  [**2097**] at [**Hospital1 112**]: LIMA->LAD; SVG->OM1; SVG->RCA
-PCI:
[**2102-5-8**]: OM3 with a proximal 95% stenosis --> POBA
[**2102-8-29**]: Failed attempt to open occluded native OM3
[**2103-5-3**]: No interventions
[**2104-9-16**]: balloon PTCA [**69**]% OM1 lesion c/b dissection of the
native LCX --> overlapping proximal distal Cypher [**Year (2 digits) **]
[**2107-2-21**]: 70% left subclavian artery stenosis --> BMS
[**2108-1-5**]: 50% left subclavian artery instent stenosis --> stented
[**2108-10-1**]: proximal 80% LAD lesion --> BMS.
[**2108-11-29**]: proximal LAD in-stent restenosis --> Xience [**Month/Day/Year **]; POBA
of LAD into the diagonal branch distal to the stent
.
3. OTHER PAST MEDICAL HISTORY:
- Aortic Stenosis/ASD s/p [**Month/Day/Year 1291**] and ASD closure ([**2107-2-22**])
- History of post-op Atrial Fibrillation
- Hypothyroidism
- Osteoarthritis
- Rheumatoid arthritis
- Iron deficiency anemia
- Depression
- Fibromyalgia
- S/P cholecystectomy ([**2108-7-9**])
- S/P appendectomy
- S/P total abdominal hysterectomy

MEDICATION ON ADMISSION: 1. Aspirin 325 mg daily
2. Clopidogrel 75 mg daily
3. Metoprolol 50 mg TID
4. Atorvastatin 80 mg daily
5. Amlodipine 5 mg daily
6. Lisinopril 40 mg daily
7. Nitrostat 0.4 mg PRN
8. Imdur 90 mg daily
9. Warfarin 7.5 mg daily
10. Levothyroxine 50 mcg daily
11. Morphine 15 mg SR Q12H
12. Morphine 15 mg Q4H PRN
13. Duloxetine 60 mg daily
14. Ascorbic Acid 1000 mg daily
15. Omeprazole 40 mg daily
16. Milk of Magnesia PRN
17. Trazodone 100 mg [**12-29**] QHS PRN
18. Ferrous Sulfate 325 mg daily
19. Acetaminophen 325 mg PRN
20. Magnesium Hydroxide PRN
21. Docusate Sodium 100 mg [**Hospital1 **]

ALLERGIES: Ambien / Percocet / Iodine; Iodine Containing

PHYSICAL EXAM: VS: BP 144/71, HR 91, 97% on room air.
GENERAL: Lying in bed.  Intermittantly tearful. Overall appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm). Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. No dentition.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular. Normal S1; mechanical S2. [**3-1**] murmur at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

SOCIAL HISTORY: No tobacco or alcohol use. Lives alone, has 3 children.
Coronary atherosclerosis of autologous vein bypass graft,Subendocardial infarction, subsequent episode of care,Congestive heart failure, unspecified,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Gout, unspecified,Dysthymic disorder,Rheumatoid arthritis,Heart valve replaced by other means,Family history of ischemic heart disease,Acquired absence of both cervix and uterus,Long-term (current) use of anticoagulants,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other complications due to other cardiac device, implant, and graft
Crn ath atlg vn bps grft,Subendo infarct, subseq,CHF NOS,Dehydration,DMII wo cmp nt st uncntr,Hypertension NOS,Hypothyroidism NOS,Iron defic anemia NOS,Gout NOS,Dysthymic disorder,Rheumatoid arthritis,Heart valve replac NEC,Fam hx-ischem heart dis,Acq absnce cervix/uterus,Long-term use anticoagul,Abn react-artif implant,Comp-oth cardiac device
Admission Date:  [**2108-12-12**]              Discharge Date:   [**2108-12-17**]

Date of Birth:  [**2047-2-3**]             Sex:   F

Service: MEDICINE

Allergies:
Ambien / Percocet / Iodine; Iodine Containing

Attending:[**Doctor First Name 1402**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
Cardiac catheterization with 2 stents placed to the LAD


History of Present Illness:
Ms. [**Known lastname 13469**] is a 61 year-old woman with a history of coronary
artery disease with CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA) with
known occluded vein grafts and recent admission with stenting to
her LAD who presents with chest pain.

Was admitted from [**11-28**] - [**12-4**] for NSTEMI.  At that time, her ECG
showed ST depressions and her CK peaked at 839 and troponin of
1.97.  Cardiac catheterization showed in-stent restenosis of her
BMS to LAD was seen which was [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 105862**].  She continued to
have chest pain post intervention and subsequently underwent
persantine MIBI on [**2108-12-3**]; this showed no reversible ischemia.
Her hospital course was complicated by intermittent junctional
rhythm and possible AV dissociation.  As a result, her
metoprolol dose was decreased.

Reports return of her anginal symptoms (back pain with radiation
to arm; chest pressure) beginning a few days after discharge.
These episodes would last minutes and would always be responsive
to nitro though she would use spray/tabs up to 14+ times per
day.  Some mild SOB and diapheresis with these episodes.  Not
always with exertion.  Overall, these episodes were similar to
those experienced after her cath on her last admission.

On the evening of admission, she returned home after shopping
and - after moving 4 bags of packages into her home - she began
to experience her angina.  It was more severe ([**8-5**]) and
persisted.  She took [**3-31**] SL nitro and many sprays without relief
and called her PCP.  [**Name10 (NameIs) **] then drove herself to an OSH.

Initially presented to an OSH where she was noted to have
ST-depressions and was given morphine, metoprolol and started on
a nitro gtt.  Troponin T returned at 0.017.

In the ED, T 98.7, HR 112, BP 209/89, RR 14.  Recieved morphine
4mg IV and dilaudid 0.5mg IV.  BP improved ot 133/95 at the time
of transfer with nitro gtt up to 0.98mcg/kg/min.

Past Medical History:
1. CARDIAC RISK FACTORS:
(-) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG:  [**2097**] at [**Hospital1 112**]: LIMA->LAD; SVG->OM1; SVG->RCA
-PCI:
[**2102-5-8**]: OM3 with a proximal 95% stenosis --> POBA
[**2102-8-29**]: Failed attempt to open occluded native OM3
[**2103-5-3**]: No interventions
[**2104-9-16**]: balloon PTCA [**69**]% OM1 lesion c/b dissection of the
native LCX --> overlapping proximal distal Cypher [**Year (2 digits) **]
[**2107-2-21**]: 70% left subclavian artery stenosis --> BMS
[**2108-1-5**]: 50% left subclavian artery instent stenosis --> stented
[**2108-10-1**]: proximal 80% LAD lesion --> BMS.
[**2108-11-29**]: proximal LAD in-stent restenosis --> Xience [**Month/Day/Year **]; POBA
of LAD into the diagonal branch distal to the stent
.
3. OTHER PAST MEDICAL HISTORY:
- Aortic Stenosis/ASD s/p [**Month/Day/Year 1291**] and ASD closure ([**2107-2-22**])
- History of post-op Atrial Fibrillation
- Hypothyroidism
- Osteoarthritis
- Rheumatoid arthritis
- Iron deficiency anemia
- Depression
- Fibromyalgia
- S/P cholecystectomy ([**2108-7-9**])
- S/P appendectomy
- S/P total abdominal hysterectomy

Social History:
No tobacco or alcohol use. Lives alone, has 3 children.


Family History:
Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

Physical Exam:
VS: BP 144/71, HR 91, 97% on room air.
GENERAL: Lying in bed.  Intermittantly tearful. Overall appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm). Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. No dentition.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular. Normal S1; mechanical S2. [**3-1**] murmur at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
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:
[**2108-12-12**] 02:14AM   GLUCOSE-109* UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-25 ANION GAP-13
[**2108-12-12**] 02:14AM   CK(CPK)-178*
[**2108-12-12**] 02:14AM   cTropnT-0.14*
[**2108-12-12**] 02:14AM   CK-MB-19* MB INDX-10.7*
[**2108-12-12**] 02:14AM   CALCIUM-9.2 PHOSPHATE-4.4 MAGNESIUM-2.1
[**2108-12-12**] 02:14AM   WBC-6.3 RBC-4.28 HGB-10.1* HCT-31.7* MCV-74*
MCH-23.5* MCHC-31.8 RDW-14.6
[**2108-12-12**] 02:14AM   NEUTS-66.8 BANDS-0 LYMPHS-25.9 MONOS-5.0
EOS-1.3 BASOS-0.9
[**2108-12-12**] 02:14AM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2108-12-12**] 02:14AM   PT-16.1* PTT-27.8 INR(PT)-1.4*

Cardiac enzymes:
[**2108-12-12**] 02:14AM BLOOD CK(CPK)-178*
[**2108-12-12**] 09:58AM BLOOD CK(CPK)-528*
[**2108-12-13**] 05:24AM BLOOD CK(CPK)-567*
[**2108-12-13**] 09:31AM BLOOD CK(CPK)-452*
[**2108-12-12**] 02:14AM BLOOD CK-MB-19* MB Indx-10.7*
[**2108-12-12**] 02:14AM BLOOD cTropnT-0.14*
[**2108-12-12**] 09:58AM BLOOD CK-MB-62* MB Indx-11.7* cTropnT-1.28*
[**2108-12-13**] 05:24AM BLOOD CK-MB-57* MB Indx-10.1* cTropnT-1.97*
[**2108-12-13**] 09:31AM BLOOD CK-MB-47* MB Indx-10.4*

STUDIES:
ECG #1 ([**12-11**] at 22:29; OSH): NST at 109.  3 PVCs noted. LVH
with LBBB morphology. ST-depressions in V3-V6 in the setting of
LVH.
ECG #2 ([**12-12**] at 0:30; [**Hospital1 **]): NST at 77.  PAC noted.  TWI in I/L
(old).  Long QT?

2D-ECHOCARDIOGRAM ([**2107-4-14**])
1. LA is moderately dilated
2. Mild symmetric LVH with normal cavity size
3. Mild regional LV systolic dysfunction with inferior
hypokinesis (LVEF 50%)
4. RV chamber size and free wall motion are normal
5. A bileaflet AV prosthesis is present
6. Mild (1+) aortic regurgitation is seen.
7. MV leaflets are mildly thickened; no mitral valve prolapse

PERSANTINE MIBI ([**2108-12-3**]):
1. Improvement of the previously described fixed inferior wall
perfusion defect. No definite new or reversible perfusion
defects identified, although the myocardium appears
heterogeneous. 2. Global hypokinesis with an LVEF of 36%.

CARDIAC CATH ([**2108-11-29**]):
- LMCA: short with diffuse disease
- LAD: 99% ISRS in the proximal LAD with TIMI 1 flow into the
diagonal
- LCX: 50-60% diffuse disease proximally
- RCA: 100% chronic proximal total occlusion
- LIMA->LAD: patent
- SVG->OM and SVG->RCA: occluded

Cardiac cath ([**12-12**]):
1- Limited selective coronary angiography of the revealed mild
disease
throughout the short LMCA and subtotal occlusion with evident
thrombosis
in the recently placed proximal LAD [**Month/Year (2) **] with extension distally
of
thrombus versus dissection into the LAD-Diagonal distribution.
The LCX
was a non-dominant vessel with diffuse 60-70% diffuse proximal
disease
(unchanged from prior). The RCA (known occluded), LIMA (known
patent)
and SVGs were not engaged (known to be occluded).
2- Limited resting hemodynamic assessment revealed normal
systemic
arterial pressure (125/66 mmHg).
3- Successful PTCA and stenting of the proximal LAD into a large
D1
branch with two overlapping 2.25x28 mm MiniVision (distal) and
2.5x18 mm
Vision (proximal) bare-metal stents, both posted with the 2.5x18
mm
stent balloon (low pressure distally, high pressure proximally).
A
contained perforation of a small branch was noted following
advancement
of the PTGI wire with no expansion of the dye capping area on
repeated
angographic views (over 15 minutes) and complete hemodynamic
stability.
A bedside echocardiogram also confirmed the absence of
pericardial
effusion.  Final angiography revealed 0% residual stenosis and
no
dissection or distal emboli. TIMI III flow was evident.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Subtotally occluded proximal LAD due to thrombosis of the
recently
placed Xience [**Month/Year (2) **] with extensive thrombus into the diagonal
branch (vs.
dissection).
3. Successful PTCA and stenting of the proximal LAD into the
diagonal
branch with two overlapping BMSs.
4- The procedure was complicated by a contained (within the
myocardium)
perforation of a small branch with dye capping that remained
stable on
repeated angiographic views.
5- Admit to CCU for overnight observation.
6. D/C Heparin and repeat echocardiogram in AM. [**Month (only) 116**] resume
Heparin if no
significant pericardial effusion.
7- Lifelong Plavix.

TTE ([**12-13**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior
hypokinesis. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. A
bileaflet aortic valve prosthesis is present. The aortic valve
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion.

Compared with the prior study (images reviewed) of [**2107-4-14**],
moderate pulmonary hypertension is now detected.

Brief Hospital Course:
#. CORONARIES/NSTEMI: The patient had a recent admission within
the last month at which time she underwent cath which showed an
instent thrombosis in the proximal LAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) 5175**].  She
Now presented with 3+ hours of chest pain and positive cardiac
biomarkers.  Her ECG at the time of admission did not show
significant change.  He chest pain improved with IV nitro.  She
underwent a cardiac catheterization given the rising cardiac
enzymes and she was found to have a subtotally occluded proximal
LAD stent (Xience 2.5x15 mm [**Last Name (Prefixes) **] placed [**2108-11-29**]) with thrombus
evident within the stent and extending distally (versus
dissection) involving the LAD-Diagonal distribution.  She had 2
BMS placed.  During the cath a guide wire entered a small branch
vessel with subsequent perforation.  An immediate TTE showed no
pericardial effusion and a repeat TTE the next am again showed
no pericardial effusion.  She was continued on plavis 75 mg
daily and ASA 81 mg daily.  She was continued on her statin and
metoprolol.  Once her nitro gtt (which was started for
hypertensive emergency as below) was weaned off she was
restarted on imdur 90 mg daily.

It is unclear why the patient presented with restenosis of her
proximal LAD stent such a short time after her recent
intervention.  If the patient represents with chest pain, a
platelet aggregation study should be checked as she may be
resistent to plavix.

#. CHEST PAIN:  The patient had another episode of chest pain
after the catheterization and stent placement with no EKG
changes.  She states that her chest pain often is triggered or
exacerbated by cold which could indicate esophageal spasm or
coronary artery spasm as a possible origin for her pain.  Other
causes include anxiety, fibromyalgia, or persistent angina from
nonvisualized coronary bloackage.  She was given ativan prn for
anxiety.  She was treated for her fibromyalgia syndrome with her
home regimen of Morphine SR and Morphine IR prn. She was started
on diltiazem 30 mg qid for esophageal spasm and it was planned
to discharge her on 120 mg daily, however this was discontinued
the day prior to discharge as she was slightly hypotensive.  She
was continued on imdur 90 mg daily and nitro prn for possible
anginal pain.

#. PUMP: The patient has a history of mild LV systolic
dysfunction, with an EF of 55%.  On admission she appeared
euvolemic on exam.  She had a TTE here which showed mild
regional left ventricular systolic dysfunction with an EF of
50-55% and increased left ventricular filling pressure.  She was
continued on lisinopril and her metoprolol (although this was
decreased from her home dose).  She had been restarted on lasix
as an outpatient, however this was held here given her low SBPs
and compelling indications for her multiple other BP
medications.

#. [**Month/Day/Year 1291**]: The patient was subtherapeutic with an INR of 1.4 on
admission.  She was started on a heparin gtt which was briefly
held after her cath given the perforation of a small branch of
her LAD, but was restarted after a TTE showed no pericardial
effusion so the heparin was restarted until her INR was
therapeutic on coumadin.  She was also restarted on coumadin and
her INR at discharge was 3.0.

#. HTN: The patient was hypertensive with SBP's in the 190's at
presentation with chest pain, consistent with hypertensive
emergency and was acutely controlled with a nitroglycerin gtt.
She was initially continued on her home amlodipine, lisinopril,
imdur, and Toprol.  Her Toprol was briefly stopped as she was
started on diltiazem as above for possible esophageal spasm and
her BP became low, however it was restarted at a lower dose of
100 mg daily and her amlodpinine and diltiazem were stopped.

#. RHYTHM: The patient has a history of atrial fibrillation, but
remained in sinus rhythm during this hospitalization.

#. DEPRESSION: The patient was continued on duloxetine.

#. HYPOTHYROIDISM: The patient was continued on her outpatient
levothyroxine dose.

#. ANEMIA: The patient is known to have a chronic microycytic
anemia and was continued on supplemental iron.


Medications on Admission:
1. Aspirin 325 mg daily
2. Clopidogrel 75 mg daily
3. Metoprolol 50 mg TID
4. Atorvastatin 80 mg daily
5. Amlodipine 5 mg daily
6. Lisinopril 40 mg daily
7. Nitrostat 0.4 mg PRN
8. Imdur 90 mg daily
9. Warfarin 7.5 mg daily
10. Levothyroxine 50 mcg daily
11. Morphine 15 mg SR Q12H
12. Morphine 15 mg Q4H PRN
13. Duloxetine 60 mg daily
14. Ascorbic Acid 1000 mg daily
15. Omeprazole 40 mg daily
16. Milk of Magnesia PRN
17. Trazodone 100 mg [**12-29**] QHS PRN
18. Ferrous Sulfate 325 mg daily
19. Acetaminophen 325 mg PRN
20. Magnesium Hydroxide PRN
21. Docusate Sodium 100 mg [**Hospital1 **]

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
[**Hospital1 **]:*60 Tablet Sustained Release(s)* Refills:*0*
4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
[**Hospital1 **]:*40 Tablet(s)* Refills:*0*
5. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
[**Hospital1 **]:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
[**Hospital1 **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*11*
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
[**Hospital1 **]:*30 Tablet, Sublingual(s)* Refills:*2*
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
[**Hospital1 **]:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
14. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed for anxiety.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
16. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for dizziness.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily
at 4 PM.
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
19. Zofran 4 mg Tablet Sig: 1-2 Tablets PO q8 hours PRN.
[**Hospital1 **]:*30 Tablet(s)* Refills:*0*
20. Nitroglycerin 0.4 mg/Dose Spray, Non-Aerosol Sig: One (1)
spray Translingual PRN: every 5 minutes as needed.
[**Hospital1 **]:*1 bottle* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Primary Diagnosis:
1. Non ST elevation myocardial infarction
2. Vertigo
3. Chest Pain

Secondary Diagnoses:
4. s/p Aortic Valve Repair
5. Depression
6. Anxiety
7. Hypothyroidism
8. Hypertension


Discharge Condition:
stable; chest pain free


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

You were admitted for chest pain.  You had a heart attack based
on the cardiac lab tests that we checked. You were taken to
cardiac catheterization, where you had a stent placed.  You had
intermittent episodes of chest pain after the procedure.  Your
home medications were adjusted to help control your chronic
chest pain.  You were started on Meclizine for vertigo.

Upon arrival to the hospital, your INR level was low, therefore
your coumadin dose was adjusted accordingly.  You must take your
medications every day, and have your INR checked regularly per
your PCP.  [**Name10 (NameIs) 357**] have your INR checked on Tuesday, [**12-18**] and send this result to your PCP.

Please continue all medications as prescribed.  The diltiazem
was stopped the day prior to discharge.  Do not take this
medicaiton.  Please keep all follow up appointments with your
physicians.

If you develop any of the following concerning symptoms, please
call your PCP, [**Name10 (NameIs) 2085**], or go to the ED: worsening chest
pains, shortness of breath, fevers, chills, nausea, or vomiting.

Followup Instructions:
Please keep your appointment on [**12-21**] with your primary doctor,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 17753**]).

Please call your cardiologist to be seen in the next 2-4 weeks.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 19117**]  [**Telephone/Fax (1) 4105**]  Follow-up appointment
should be in 1 month

Please have your INR checked on Tuesday, [**12-18**] and send
these results to your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].



Completed by:[**2108-12-17**]
{'Coronary atherosclerosis of autologous vein bypass graft,Subendocardial infarction, subsequent episode of care,Congestive heart failure, unspecified,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Gout, unspecified,Dysthymic disorder,Rheumatoid arthritis,Heart valve replaced by other means,Family history of ischemic heart disease,Acquired absence of both cervix and uterus,Long-term (current) use of anticoagulants,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other complications due to other cardiac device, implant, and graft'}


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: Ms. [**Known lastname 13469**] is a 61 year-old woman with a history of coronary
artery disease with CABG x 3 (LIMA-LAD, SVG-OM, SVG-RCA) with
known occluded vein grafts and recent admission with stenting to
her LAD who presents with chest pain.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:
(-) Diabetes
(+) Dyslipidemia
(+) Hypertension
.
2. CARDIAC HISTORY:
-CABG:  [**2097**] at [**Hospital1 112**]: LIMA->LAD; SVG->OM1; SVG->RCA
-PCI:
[**2102-5-8**]: OM3 with a proximal 95% stenosis --> POBA
[**2102-8-29**]: Failed attempt to open occluded native OM3
[**2103-5-3**]: No interventions
[**2104-9-16**]: balloon PTCA [**69**]% OM1 lesion c/b dissection of the
native LCX --> overlapping proximal distal Cypher [**Year (2 digits) **]
[**2107-2-21**]: 70% left subclavian artery stenosis --> BMS
[**2108-1-5**]: 50% left subclavian artery instent stenosis --> stented
[**2108-10-1**]: proximal 80% LAD lesion --> BMS.
[**2108-11-29**]: proximal LAD in-stent restenosis --> Xience [**Month/Day/Year **]; POBA
of LAD into the diagonal branch distal to the stent
.
3. OTHER PAST MEDICAL HISTORY:
- Aortic Stenosis/ASD s/p [**Month/Day/Year 1291**] and ASD closure ([**2107-2-22**])
- History of post-op Atrial Fibrillation
- Hypothyroidism
- Osteoarthritis
- Rheumatoid arthritis
- Iron deficiency anemia
- Depression
- Fibromyalgia
- S/P cholecystectomy ([**2108-7-9**])
- S/P appendectomy
- S/P total abdominal hysterectomy

MEDICATION ON ADMISSION: 1. Aspirin 325 mg daily
2. Clopidogrel 75 mg daily
3. Metoprolol 50 mg TID
4. Atorvastatin 80 mg daily
5. Amlodipine 5 mg daily
6. Lisinopril 40 mg daily
7. Nitrostat 0.4 mg PRN
8. Imdur 90 mg daily
9. Warfarin 7.5 mg daily
10. Levothyroxine 50 mcg daily
11. Morphine 15 mg SR Q12H
12. Morphine 15 mg Q4H PRN
13. Duloxetine 60 mg daily
14. Ascorbic Acid 1000 mg daily
15. Omeprazole 40 mg daily
16. Milk of Magnesia PRN
17. Trazodone 100 mg [**12-29**] QHS PRN
18. Ferrous Sulfate 325 mg daily
19. Acetaminophen 325 mg PRN
20. Magnesium Hydroxide PRN
21. Docusate Sodium 100 mg [**Hospital1 **]

ALLERGIES: Ambien / Percocet / Iodine; Iodine Containing

PHYSICAL EXAM: VS: BP 144/71, HR 91, 97% on room air.
GENERAL: Lying in bed.  Intermittantly tearful. Overall appears
comfortable.
HEENT: NCAT. Sclera anicteric. PERRL (3mm --> 2mm). Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma. No dentition.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Regular. Normal S1; mechanical S2. [**3-1**] murmur at LUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

SOCIAL HISTORY: No tobacco or alcohol use. Lives alone, has 3 children. 

### Response:
{'Coronary atherosclerosis of autologous vein bypass graft,Subendocardial infarction, subsequent episode of care,Congestive heart failure, unspecified,Dehydration,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Iron deficiency anemia, unspecified,Gout, unspecified,Dysthymic disorder,Rheumatoid arthritis,Heart valve replaced by other means,Family history of ischemic heart disease,Acquired absence of both cervix and uterus,Long-term (current) use of anticoagulants,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other complications due to other cardiac device, implant, and graft'}
