CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 76M with hx of CAD s/p CABG x 2 ([**2140**],[**2148**]), multiple NSTEMI,
and PTCA ([**2154**],[**2156**]), HTN, DM2, MM on dex/Revlimid/Velcade
presents with chest pain. It started at 5pm and went away with
SL nitro at home. Returned at 6pm, took another nitro which did
not help. Chest pain similar in quality to pain with prior MIs.
Called 911. EMS gave ASA 325mg, morphine 4mg, and another SL
nitro.
.
Of note, patient was recently d/c'ed from [**Hospital1 2025**] on [**9-30**] after
NSTEMI with trop to 0.25 complicated by cardiac catherization in
which rotoblade became lodged in the left circumflex. CT surgery
felt emergent bypass was not possible. ECG at this time showed
STDs in V1-V5, II, III, and aVF. He was admitted to the CCU,
started on nitro gtt and lasix. He was medically managed with
ASA, carvedilol, statin. Not anticoagulated given his
thrombocytopenia and hx of HIT. The blade was thought to be the
cause of a subsequent left lateral wall infarction, leading to
inferior wall hypokinesis, mod/severe MR due to papillary muscle
infarct, and a drop in EF from 60 to 40%. Patient was
subsequently re-admitted to [**Hospital1 2025**] from [**Date range (1) 112543**] for recurrent
chest pain and rising troponins (peaked at 2.27) thought to be
related to continuing infarction.
.
Currently on Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). Episode of chest pain leading to first [**Hospital1 2025**] admission
was also preceded by chemotherapy that day.
.
In the ED, initial vitals were 7, 96.0, 74, 132/89, 18, 99% 4L.
ECG showed ST depressions in V3-V6. Labs and imaging significant
for lactate 4.1, trop 0.65, glu 381 with gap 13, UA with trace
ketones and large glucose, calcium 10.9, WBC 2.5, Hct 30.8, Plt
92, and INR 1.4. CXR showed small bilateral effusions and some
vascular fullness. In the ER, the patient still c/o of CP after
additional SL nitro.  Chest pain improved with morphine, but did
not resolve. Chest pain finally resolved with nitro gtt.
.
On arrival to the [**Hospital1 18**] CCU, patient was free of chest pain.
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L.

MEDICAL HISTORY: - Diabetes
- Dyslipidemia
- Hypertension
- CABG: [**2140**] 3v with LIMA to LAD, double right sided SVG; [**2148**]
redo SVG to circumflex OM1, main right and posterior left
ventricular coronary arteries
- [**2144**] stent placement to vein in RCA; [**2156**] native distal LAD to
LIMA anastomosis
- T2 [**Doctor Last Name **] 8 prostate ca x/p XRT
- Multiple myeloma diagnosed in [**7-/2163**] on revlemid/velcade/dex
(cycle 2 day 1 [**2163-10-13**])
- Gout
- Type II HIT (PF4 Ab positive)

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  dc summary.
1. Valsartan 20 mg PO DAILY
2. Oxybutynin 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Pravastatin 40 mg PO HS
7. Allopurinol 300 mg PO DAILY
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D [**2151**] UNIT PO DAILY
10. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Isosorbide Dinitrate 40 mg PO TID
12. Fish Oil (Omega 3) 600 mg PO DAILY

ALLERGIES: Heparin Agents / Lipitor / Statins-Hmg-Coa Reductase Inhibitors

PHYSICAL EXAM: ADMISSION:
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L
GENERAL: WDWN M 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: No h/o heart disease. Father died of esophageal cancer.

SOCIAL HISTORY: -Tobacco history: 1ppd x 21 years, quit [**2126**]
-ETOH: negative
-Illicit drugs: negative
-Lives with his wife.
Coronary atherosclerosis of unspecified type of vessel, native or graft,Acute on chronic systolic heart failure,Multiple myeloma, without mention of having achieved remission,Intermediate coronary syndrome,Old myocardial infarction,Unspecified essential hypertension,Subendocardial infarction, subsequent episode of care,Gout, unspecified,Thrombocytopenia, unspecified,Aortocoronary bypass status,Do not resuscitate status,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled
Cor ath unsp vsl ntv/gft,Ac on chr syst hrt fail,Mult mye w/o achv rmson,Intermed coronary synd,Old myocardial infarct,Hypertension NOS,Subendo infarct, subseq,Gout NOS,Thrombocytopenia NOS,Aortocoronary bypass,Do not resusctate status,DMII wo cmp uncntrld
Admission Date:  [**2163-10-13**]              Discharge Date:   [**2163-10-17**]

Date of Birth:  [**2087-6-20**]             Sex:   M

Service: MEDICINE

Allergies:
Heparin Agents / Lipitor / Statins-Hmg-Coa Reductase Inhibitors

Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
None

History of Present Illness:
76M with hx of CAD s/p CABG x 2 ([**2140**],[**2148**]), multiple NSTEMI,
and PTCA ([**2154**],[**2156**]), HTN, DM2, MM on dex/Revlimid/Velcade
presents with chest pain. It started at 5pm and went away with
SL nitro at home. Returned at 6pm, took another nitro which did
not help. Chest pain similar in quality to pain with prior MIs.
Called 911. EMS gave ASA 325mg, morphine 4mg, and another SL
nitro.
.
Of note, patient was recently d/c'ed from [**Hospital1 2025**] on [**9-30**] after
NSTEMI with trop to 0.25 complicated by cardiac catherization in
which rotoblade became lodged in the left circumflex. CT surgery
felt emergent bypass was not possible. ECG at this time showed
STDs in V1-V5, II, III, and aVF. He was admitted to the CCU,
started on nitro gtt and lasix. He was medically managed with
ASA, carvedilol, statin. Not anticoagulated given his
thrombocytopenia and hx of HIT. The blade was thought to be the
cause of a subsequent left lateral wall infarction, leading to
inferior wall hypokinesis, mod/severe MR due to papillary muscle
infarct, and a drop in EF from 60 to 40%. Patient was
subsequently re-admitted to [**Hospital1 2025**] from [**Date range (1) 112543**] for recurrent
chest pain and rising troponins (peaked at 2.27) thought to be
related to continuing infarction.
.
Currently on Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). Episode of chest pain leading to first [**Hospital1 2025**] admission
was also preceded by chemotherapy that day.
.
In the ED, initial vitals were 7, 96.0, 74, 132/89, 18, 99% 4L.
ECG showed ST depressions in V3-V6. Labs and imaging significant
for lactate 4.1, trop 0.65, glu 381 with gap 13, UA with trace
ketones and large glucose, calcium 10.9, WBC 2.5, Hct 30.8, Plt
92, and INR 1.4. CXR showed small bilateral effusions and some
vascular fullness. In the ER, the patient still c/o of CP after
additional SL nitro.  Chest pain improved with morphine, but did
not resolve. Chest pain finally resolved with nitro gtt.
.
On arrival to the [**Hospital1 18**] CCU, patient was free of chest pain.
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L.

Past Medical History:
- Diabetes
- Dyslipidemia
- Hypertension
- CABG: [**2140**] 3v with LIMA to LAD, double right sided SVG; [**2148**]
redo SVG to circumflex OM1, main right and posterior left
ventricular coronary arteries
- [**2144**] stent placement to vein in RCA; [**2156**] native distal LAD to
LIMA anastomosis
- T2 [**Doctor Last Name **] 8 prostate ca x/p XRT
- Multiple myeloma diagnosed in [**7-/2163**] on revlemid/velcade/dex
(cycle 2 day 1 [**2163-10-13**])
- Gout
- Type II HIT (PF4 Ab positive)

Social History:
-Tobacco history: 1ppd x 21 years, quit [**2126**]
-ETOH: negative
-Illicit drugs: negative
-Lives with his wife.

Family History:
No h/o heart disease. Father died of esophageal cancer.


Physical Exam:
ADMISSION:
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L
GENERAL: WDWN M 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 with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No wheezes or rhonchi.
Mild decrease in breath sounds bilaterally. Crackles at the L
base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT dopplerable
Left: DP 2+ PT 1+
.
DISCHARGE:
GENERAL: WDWN M 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 with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No wheezes or rhonchi.
Mild decrease in breath sounds bilaterally. Crackles at the L
base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT dopplerable
Left: DP 2+ PT 1+

Pertinent Results:
ADMISSION:
[**2163-10-13**] 08:02PM BLOOD WBC-2.5* RBC-3.19* Hgb-10.8* Hct-30.8*
MCV-97 MCH-33.8* MCHC-34.9 RDW-17.1* Plt Ct-92*
[**2163-10-13**] 08:02PM BLOOD PT-15.1* PTT-34.7 INR(PT)-1.4*
[**2163-10-13**] 08:02PM BLOOD Glucose-381* UreaN-22* Creat-0.8 Na-133
K-4.9 Cl-99 HCO3-21* AnGap-18
[**2163-10-13**] 08:02PM BLOOD ALT-31 AST-43* AlkPhos-118 TotBili-0.9
[**2163-10-14**] 01:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2163-10-13**] 08:02PM BLOOD Calcium-10.9* Phos-3.3 Mg-1.7
.
STUDIES:
([**10-13**]) CXR:IMPRESSION:  Mild pulmonary edema with bilateral
small pleural effusions, left greater than right, and adjacent
atelectasis.
.
([**10-15**]) CXR: There is substantial interval improvement up to
almost complete resolution of pulmonary edema.  Heart size and
mediastinum are unchanged in appearance including tortuous
aorta.  Small amount of pleural effusion cannot be excluded.
There is no pneumothorax.
.
([**10-14**]) ECHO:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the basal half of the inferior
and inferolateral walls. The remaining segments contract
normally (LVEF = 40-45 %). The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (PDA
distribution). Moderate mitral regurgitation most likely due to
papillary muscle dysfunction. Dilated ascending aorta. Pulmonary
artery hypertension.
CLINICAL IMPLICATIONS:
The patient has moderate mitral regurgitation. Based on [**2157**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 1 year. The patient has a mildly
dilated ascending aorta. Based on [**2161**] ACCF/AHA Thoracic Aortic
Guidelines, if not previously known or a change, a follow-up
echocardiogram is suggested in 1 year; if previously known and
stable, a follow-up echocardiogram is suggested in [**2-25**] years.
Based on [**2158**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
OTHER LAB RESULTS:
[**2163-10-17**] 06:03AM BLOOD WBC-1.8* RBC-3.12* Hgb-10.4* Hct-29.7*
MCV-95 MCH-33.3* MCHC-35.0 RDW-16.9* Plt Ct-59*
[**2163-10-16**] 03:05AM BLOOD PT-14.0* PTT-31.7 INR(PT)-1.3*
[**2163-10-17**] 06:03AM BLOOD Glucose-148* UreaN-14 Creat-0.4* Na-135
K-4.0 Cl-103 HCO3-27 AnGap-9
[**2163-10-14**] 03:10PM BLOOD CK(CPK)-43*
[**2163-10-14**] 03:10PM BLOOD CK-MB-4 cTropnT-0.71*
[**2163-10-14**] 08:40AM BLOOD CK-MB-5 cTropnT-0.69*
[**2163-10-14**] 01:43AM BLOOD CK-MB-4 cTropnT-0.54*
[**2163-10-17**] 06:03AM BLOOD Calcium-9.6 Phos-2.7 Mg-1.9
[**2163-10-14**] 02:16AM BLOOD Lactate-3.8*
.
EKGs: 2-3mm ST depressions in V3-V6 on admission; these
decreased to ~1mm ST depressions on discharge when patient was
asymptomatic

Brief Hospital Course:
76M with extensive hx of CAD including multiple CABG with most
recent cath on [**9-23**] c/b rotorblade impaction in the LCx presents
to ED with chest pain, elevated troponin, and EKG changes. The
chest pain appears to be associated with the timing of his
chemotherapy for multiple myeloma.
.
# Chest Pain: Suspect demand ischemia secondary to chemotherapy
agents (direct effect or volume induced pulmonary edema). Based
on literature review, cardiac effects commonly seen with
Revlimid/Velcade, and given his EF 45%, some aspect of overload
could also contribute to this problem. In CCU, pt had an episode
of [**9-2**] chest pain accompanied by shortness of breath and
increased O2 requirement, which was likely ischemia with flash
pulmonary edema. This resolved with Lasix, nitro drip, beta
blocker, and morphine. Following this episode, he was without
pain, and enzymes show negative CKMB and mildly elevated trop,
indicating likely ischemia rather than new infarct. Nitro gtt
was weaned later the day of admission, and he was placed on
Imdur 30mg/day (in place of home isosorbide dinitrate). Pt was
continued on ASA 81, but Plavix was held given thrombocytopenia
(PLT in 50s). We continued his home BB (Metop tartrate 50 [**Hospital1 **],
which was eventually switched to metop succinate XL 100mg
daily), [**Last Name (un) **] (Valsartan 20 daily), and statin (pravastatin 80mg,
increased from home dose of 40mg daily). We spoke with oncology,
and they recommended holding chemotherapy in case it is
implicated in the patient's demand ischemia. We communicated
this to a covering colleague of the patient's outside
oncologist.  The oncologist may need to adjust the chemotherapy
regimen to avoid further cardiac issues. On day of discharge, pt
was without CP or SOB; he was breathing room air, had flat neck
veins, trace ankle edema, and his lung sounds were clear.
.
# Acute on Chronic Systolic CHF:  No change in LVEF on repeat
ECHO (40%). Pt was admitted with oxygen requirement to 4L NC. On
the first morning of his admission, he had what appeared to be
an episode of flash pulmonary edema, which resolved with
metoprolol, nitro drip, morphine, and Lasix. O2 was weaned over
2 days to room air on discharge (his baseline). CXR showed
significant acute pulmonary edema which resolved over the next
several days with diuresis. Electrolytes were stable and wnl
during the diuresis. Pt was started on PO Lasix 40/day prior to
discharge.
.
# Multiple Myeloma: Currently on chemo with pancytopenia without
evidence of bleeding. Patient is neutropenic and afebrile. Cr
WNL. Pt received Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). The patient will meet with his oncologist on the day
following discharge to discuss the potential impact of his
chemotherapy on his cardiac disease and whether there are
alternative agents.
.
# DM2: Patient was on high doses of home insulin with blood
sugar in 300s and glucose in his urine. Pt was seen by [**Last Name (un) **]
(endocrinology consult) who recommended 70U Lantus qHS, then
standing 15U Humalog prior to each meal with ISS after. Will
need to monitor closely as outpatient. He has follow up with his
PCP the day after discharge.
.
# GOUT: Not active. We continued home allopurinol.
.
TRANSITIONAL
- Will need to avoid prior chemotherapy regimen (he has
appointment with Dr.[**Name (NI) 7517**] the day following discharge)
- Will need to follow his blood sugar control with outpatient
PCP and home [**Name9 (PRE) 269**]
- Will send d/c summary to cardiologist Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 79852**] at
[**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 20468**] (he has an appointment with him in early
[**Month (only) 359**])
- Patient is confirmed DNI/DNR

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  dc summary.
1. Valsartan 20 mg PO DAILY
2. Oxybutynin 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Pravastatin 40 mg PO HS
7. Allopurinol 300 mg PO DAILY
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D [**2151**] UNIT PO DAILY
10. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Isosorbide Dinitrate 40 mg PO TID
12. Fish Oil (Omega 3) 600 mg PO DAILY


Discharge Medications:
1. Allopurinol 300 mg PO DAILY
RX *allopurinol 300 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
2. Aspirin 81 mg PO DAILY
3. Glargine 70 Units Bedtime
Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Oxybutynin 10 mg PO DAILY
5. Pravastatin 80 mg PO HS
RX *pravastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
6. Prochlorperazine 10 mg PO Q8H:PRN nausea
7. Valsartan 20 mg PO DAILY
8. Vitamin D [**2151**] UNIT PO DAILY
9. Furosemide 40 mg PO DAILY
Hold for SBP<90
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<90
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
11. Metoprolol Succinate XL 100 mg PO DAILY
Hold for SBP<90, HR<60
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
12. Fish Oil (Omega 3) 600 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL PRN chest pain


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Coronary artery disease
Acute coronary syndrome
Acute on chronic systolic heart failure
Diabetes


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


Discharge Instructions:
Dear Mr. [**Known lastname 112544**],

Thank you for choosing [**Hospital1 18**]. You were admitted to the hospital
for chest pain. Your symptoms are related to your coronary
artery disease. Your acute increase in chest pain may have been
related to the chemotherapy that you received prior to
admission. Please talk to your oncologist at your appointment
tomorrow about alternative medications for your multiple
myeloma.

You were also found to have extra fluid around your lungs, which
we think was related to "heart failure," that is, decreased
ability of your heart to pump blood. This improved significantly
after you received water pills (Lasix, also known as
furosemide). Please follow up with your cardiologist on [**10-27**] about the ongoing treatment of your heart disease.

While you were in the hospital, you were seen by our diabetes
specialist who recommended some changes in your insulin doses to
better control your blood sugars. Attached you will find
specific information about how much insulin you should take and
when. Please follow up with your primary care doctor tomorrow
about ongoing treatment of your diabetes.

We made the following changes to your medications:

STOP
- isosorbide dinitrate
- metoprolol tartrate

START
- furosemide 40 mg daily
- isosorbide mononitrate extended release 30 mg daily
- metoprolol succinate XL 100mg daily

CHANGES IN DOSE
- pravastatin, now take 80 mg daily
- insulin (see attached for details)

Thank you for allowing us to take part in your care.

Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112545**],MD
Specialty: Hematology/Oncology
When: Tuesday [**2163-10-18**] at 9am
Location: [**Hospital **] CANCER CENTER
Address: [**2163**], [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 83767**]
Please be sure to keep this appointment. You need to see Dr.
[**Last Name (STitle) **] before your next chemotherapy appointment.

Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Specialty: Primary Care and Endocrinology
When: Tuesday [**2163-10-18**] at 1:30pm
Address: [**State **], [**Apartment Address(1) 101800**], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 98031**]
** It is VERY important that you keep this appointment. The
office is closed on Wednesday and you need to be seen soon after
discharge from the hospital.

Name: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 112546**], MD
Specialty: Cardiology
When: Thursday [**2163-10-27**] at 8:40am
Location: [**Hospital1 **] CARDIOLOGISTS
Address: [**2163**] STE. 562, [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 18278**]
{'Coronary atherosclerosis of unspecified type of vessel, native or graft,Acute on chronic systolic heart failure,Multiple myeloma, without mention of having achieved remission,Intermediate coronary syndrome,Old myocardial infarction,Unspecified essential hypertension,Subendocardial infarction, subsequent episode of care,Gout, unspecified,Thrombocytopenia, unspecified,Aortocoronary bypass status,Do not resuscitate status,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}


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: 76M with hx of CAD s/p CABG x 2 ([**2140**],[**2148**]), multiple NSTEMI,
and PTCA ([**2154**],[**2156**]), HTN, DM2, MM on dex/Revlimid/Velcade
presents with chest pain. It started at 5pm and went away with
SL nitro at home. Returned at 6pm, took another nitro which did
not help. Chest pain similar in quality to pain with prior MIs.
Called 911. EMS gave ASA 325mg, morphine 4mg, and another SL
nitro.
.
Of note, patient was recently d/c'ed from [**Hospital1 2025**] on [**9-30**] after
NSTEMI with trop to 0.25 complicated by cardiac catherization in
which rotoblade became lodged in the left circumflex. CT surgery
felt emergent bypass was not possible. ECG at this time showed
STDs in V1-V5, II, III, and aVF. He was admitted to the CCU,
started on nitro gtt and lasix. He was medically managed with
ASA, carvedilol, statin. Not anticoagulated given his
thrombocytopenia and hx of HIT. The blade was thought to be the
cause of a subsequent left lateral wall infarction, leading to
inferior wall hypokinesis, mod/severe MR due to papillary muscle
infarct, and a drop in EF from 60 to 40%. Patient was
subsequently re-admitted to [**Hospital1 2025**] from [**Date range (1) 112543**] for recurrent
chest pain and rising troponins (peaked at 2.27) thought to be
related to continuing infarction.
.
Currently on Revlimid/Velcade/dex for MM (cycle 2, day 1
[**2163-10-13**]). Episode of chest pain leading to first [**Hospital1 2025**] admission
was also preceded by chemotherapy that day.
.
In the ED, initial vitals were 7, 96.0, 74, 132/89, 18, 99% 4L.
ECG showed ST depressions in V3-V6. Labs and imaging significant
for lactate 4.1, trop 0.65, glu 381 with gap 13, UA with trace
ketones and large glucose, calcium 10.9, WBC 2.5, Hct 30.8, Plt
92, and INR 1.4. CXR showed small bilateral effusions and some
vascular fullness. In the ER, the patient still c/o of CP after
additional SL nitro.  Chest pain improved with morphine, but did
not resolve. Chest pain finally resolved with nitro gtt.
.
On arrival to the [**Hospital1 18**] CCU, patient was free of chest pain.
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L.

MEDICAL HISTORY: - Diabetes
- Dyslipidemia
- Hypertension
- CABG: [**2140**] 3v with LIMA to LAD, double right sided SVG; [**2148**]
redo SVG to circumflex OM1, main right and posterior left
ventricular coronary arteries
- [**2144**] stent placement to vein in RCA; [**2156**] native distal LAD to
LIMA anastomosis
- T2 [**Doctor Last Name **] 8 prostate ca x/p XRT
- Multiple myeloma diagnosed in [**7-/2163**] on revlemid/velcade/dex
(cycle 2 day 1 [**2163-10-13**])
- Gout
- Type II HIT (PF4 Ab positive)

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  dc summary.
1. Valsartan 20 mg PO DAILY
2. Oxybutynin 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Pravastatin 40 mg PO HS
7. Allopurinol 300 mg PO DAILY
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Vitamin D [**2151**] UNIT PO DAILY
10. Glargine 70 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Isosorbide Dinitrate 40 mg PO TID
12. Fish Oil (Omega 3) 600 mg PO DAILY

ALLERGIES: Heparin Agents / Lipitor / Statins-Hmg-Coa Reductase Inhibitors

PHYSICAL EXAM: ADMISSION:
Vitals were 98.1, 80, 127/82, 12, and 97% on 2L
GENERAL: WDWN M 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: No h/o heart disease. Father died of esophageal cancer.

SOCIAL HISTORY: -Tobacco history: 1ppd x 21 years, quit [**2126**]
-ETOH: negative
-Illicit drugs: negative
-Lives with his wife. 

### Response:
{'Coronary atherosclerosis of unspecified type of vessel, native or graft,Acute on chronic systolic heart failure,Multiple myeloma, without mention of having achieved remission,Intermediate coronary syndrome,Old myocardial infarction,Unspecified essential hypertension,Subendocardial infarction, subsequent episode of care,Gout, unspecified,Thrombocytopenia, unspecified,Aortocoronary bypass status,Do not resuscitate status,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled'}
