CHIEF COMPLAINT: CP; transfer for cardiac catheterization

PRESENT ILLNESS: 82 yo with hx of DM, CAD s/p CABG [**2152**] redo [**10/2171**], CHF (EF 51%)
admitted to [**Hospital **] Hospital on [**1-7**] with CP. His course was
complicated by DTs [**1-29**] etoh w/d and he was intubated in the ICU.
He was in normal healthy until the am of [**1-7**] when he
experienced [**7-6**] substernal CP which was "squeezing" while
watching TV.  It lasted for 30 minutes without associated
radiation, SOB, nausea, diaphoresis, palpitations or
lightheadedness.  He did not take medications for this incident.
 After dinner he lies down normally for approx 1/2 hour but has
noticed SOB when supine over the past week.  He has gained 30
lbs over the last year.  He has had CP approximately 1X/year for
which he usually takes Nitro.

MEDICAL HISTORY: - CAD s/p cabg [**2152**] with redo in [**10/2171**] at [**Hospital1 18**] see OMR for
complete graft information.
- [**2171**]: stent
- Diabetes diagnosed in [**2152**]
- CHF with EF 55%
- Hypercholesterolanemia
- ETOH abuse drinks a pint of whiskey a day DT's in the past
- Multiple falls
- GERD
- Anxiety/depression
- Obesity
- TIA [**2161**]
.
TTE: EF 55% 7/05

MEDICATION ON ADMISSION: CURRENT MEDICATIONS:
Home medications ([**First Name8 (NamePattern2) **] [**Hospital **] Hospital which had contact[**Name (NI) **] CVS)
[**Name (NI) 28865**] 4mg daily
Ativan 1mg [**Hospital1 **] prn
Metolazone 2.5 mg twice a week
Insulin, 52U [**Hospital1 **] per patient
?Spironolactone 25mg daily not refilled since [**9-5**]
ASA
Plavix
Gabapentin 600mg QHS
.
Medications on transfer:
Prilosec 40mg daily
Heparin SC 5000U TID
Insulin NPH 20U [**Hospital1 **] before meals
Insulin s/s: 131-180 4 U, 181-240 8U, 241-300 10U, 301-350 12U,
351-400 16U
Robitussin syrup
MOM 30ml daily
Senokot prn
Tyelnol 650mg Q4H
Nitrostat 0.4mg prn
Mucomyst [**Hospital1 **]
ASA 81mg daily
Lipitor 80mg daily
OscalD 500mg [**Hospital1 **]
Plavix 75mg daily
Lasix 40mg daily
Neurontin 600mg daily HS
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS -  98.1, 126/64, 18, 94%/RA
Gen: NAD. Oriented x3. Mood appropriate, affect inpatient and
axious.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
Neck: unable to assess JVP.
CV: RR, normal S1, 2/6 SEM. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Shallow BS.
Abd: Soft, NTND. No HSM or tenderness. No femoral bruits.
Ext: 2+ b/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. 2+ DPs
Skin: significant erythema (chronic) anterior left shin; SCV
line on right NT without erythema

FAMILY HISTORY: Father died at 47 of CAD, Mother died at 73 of CAD.

SOCIAL HISTORY: Married with supportive wife who helps with medications.
tob: quit [**2150**]
etoh: 1 pint whiskey/day.  Has had hospitalization for w/d in
the past
Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Coronary atherosclerosis of autologous vein bypass graft,Other complications due to other cardiac device, implant, and graft,Alcohol withdrawal delirium,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,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 other specified places,Acute alcoholic intoxication in alcoholism, continuous,Dysthymic disorder,Other chronic pulmonary heart diseases,Other specified cardiac dysrhythmias,Mitral valve insufficiency and aortic valve stenosis,Altered mental status
Subendo infarct, initial,Acute respiratry failure,Ac on chr syst hrt fail,Crbl emblsm w infrct,Food/vomit pneumonitis,Crn ath atlg vn bps grft,Comp-oth cardiac device,Delirium tremens,DMII wo cmp nt st uncntr,Hypertension NOS,Abn react-cardiac cath,Accident in place NEC,Ac alcohol intox-contin,Dysthymic disorder,Chr pulmon heart dis NEC,Cardiac dysrhythmias NEC,Mitral insuf/aort stenos,Altered mental status
Admission Date:  [**2182-1-21**]              Discharge Date:   [**2182-2-18**]

Date of Birth:  [**2099-10-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
CP; transfer for cardiac catheterization

Major Surgical or Invasive Procedure:
cardiac cathererization with drug eluting stent to LIMA graft of
Left anterior descending artery


History of Present Illness:
82 yo with hx of DM, CAD s/p CABG [**2152**] redo [**10/2171**], CHF (EF 51%)
admitted to [**Hospital **] Hospital on [**1-7**] with CP. His course was
complicated by DTs [**1-29**] etoh w/d and he was intubated in the ICU.
He was in normal healthy until the am of [**1-7**] when he
experienced [**7-6**] substernal CP which was "squeezing" while
watching TV.  It lasted for 30 minutes without associated
radiation, SOB, nausea, diaphoresis, palpitations or
lightheadedness.  He did not take medications for this incident.
 After dinner he lies down normally for approx 1/2 hour but has
noticed SOB when supine over the past week.  He has gained 30
lbs over the last year.  He has had CP approximately 1X/year for
which he usually takes Nitro.

Patient's history is currently more variable.  He reports CP the
night prior to presentation for which he took SL Nitro X3. He
had chest pain the next am which did not respond to Nitro.  He
had assocaited nausea.  Patient notes that he had seizures
during these episodes- as he gets seizures the more he drinks.
However, he states that he has not had a drink in 3 weeks since
he went to rehab 2 weeks ago after being given an ultamatum by
his wife.

He went to the ED, and on the way experienced substernal chest
squeezing, [**4-6**] which lasted a couple of minutes and resolved
spontaneously. In the ED his VS were: 98.3, 92, 136/78, 92%/RA.
His SBP dropped to 77 and he received 2L NS and ASA.

He was initially started on high dose PPI given suspicion for
reflux.

The patient noted orthopnea and was found to be in respiratory
distress.  He was admitted to the ICU with CHF and etoh
withdrawal. He was agitated, tachycardic and hypertensive and
then dyspneic with 3 inches of nitro paste, 120mg Lasix, 6mg IV
ativan, 8mg IV morphine, 10mg IV lopressor.  He required
intubation for hypoxemic respiratory failure as his RR was 45,
he was sating 85% on NRB. He was treated while intubated with
Versed and Fentanyl. He was treated with Unasyn for a question
of aspiration pneumonia.  He was extubated on [**1-14**] with
continued aggressive diuresis.

He ruled in for a NSTEMI with Trops up to 1.5.
He was intubated and admitted ot he ICU and extubated on [**1-14**].
He was also requiring detox secondary to etoh abuse.

On [**1-18**] he had a Persantine stress with HR to the 80s, <70% of
target, with no ischemic EKG changes. APBs in receovery.
Negative sxs for angina. Nuclear imaging revealed LVEF 51%,
septal/inf wall and apical hypokineais with large mixed,
primarily ischemic septal defect extending into the anterior
wall. There was a mod/large inferior mixed, primaritly ischemic
defect extending into a portion of the lateral wall with apical
ischemia. There was a suggestion of LV dilation.

ROS negative for fevers or chills.  Positive for cough and
sputum which is present more when he drinks. He has had dysuria
since having the foley catheter at the OSH.
Cardiac review of systems is notable for absence of current
chest pain. He does have dyspnea on exertion, orthopnea, ankle
edema. Denies palpitations.

Past Medical History:
- CAD s/p cabg [**2152**] with redo in [**10/2171**] at [**Hospital1 18**] see OMR for
complete graft information.
- [**2171**]: stent
- Diabetes diagnosed in [**2152**]
- CHF with EF 55%
- Hypercholesterolanemia
- ETOH abuse drinks a pint of whiskey a day DT's in the past
- Multiple falls
- GERD
- Anxiety/depression
- Obesity
- TIA [**2161**]
.
TTE: EF 55% 7/05

Social History:
Married with supportive wife who helps with medications.
tob: quit [**2150**]
etoh: 1 pint whiskey/day.  Has had hospitalization for w/d in
the past

Family History:
Father died at 47 of CAD, Mother died at 73 of CAD.

Physical Exam:
VS -  98.1, 126/64, 18, 94%/RA
Gen: NAD. Oriented x3. Mood appropriate, affect inpatient and
axious.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
Neck: unable to assess JVP.
CV: RR, normal S1, 2/6 SEM. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Shallow BS.
Abd: Soft, NTND. No HSM or tenderness. No femoral bruits.
Ext: 2+ b/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. 2+ DPs
Skin: significant erythema (chronic) anterior left shin; SCV
line on right NT without erythema

Pertinent Results:
EKG compared to [**2171-11-19**]: NSR 84, NA, mild PR prelongation
stable from prior, NL QRS, NL QTc, Q waves II, AvF new from
prior, loss of R wave progression from prior

OSH:
[**1-8**] UA: trace protein, large blood, neg nitrite, 119 RBC, 2
WBC, <1 sq, few bacteria
[**1-7**]: ethyl etoh 193
130/4/96/25/9/0.9<64
Ca 8.8
.
CPK 82, MB 2.8, Index: 4.6
        MB 54.4
Trop I 0.09
       1.59 (unclear time or date)
.
Alb 3.6
.
5.7>35.9<155 (WBC peaked at 9.1 on [**1-21**])
PT 14.1, INR 1.1, PTT 25.2
BNP 151
.
b/l LE u/s: [**1-9**] no DVT bit valf levels not fully evaluated [**1-29**]
edema
CXR: cardiomegaly with pulmonary vasculature congestion on [**1-14**]
repeated on [**1-16**] which showed improvement in b/l pleural
effusions.
EKG: NSR 94 with septal infarct
.
sputum ctx: at OSH
blood ctx: at OSH
.
CXR [**1-21**]: The uppermost and the lowest sternal wires are
fractured and although a fragment of the lowest wire has
migrated laterally, the alignment of the sutures is as expected
and undisturbed. Lungs are clear. Heart is mildly enlarged.
There is no appreciable pleural effusion. Right subclavian line
tip is just above the junction of the brachiocephalic veins. No
pneumothorax, mediastinal widening or pleural effusion.
.
Admission labs:
[**2182-1-21**] 06:46PM BLOOD WBC-6.8 RBC-3.41* Hgb-10.8* Hct-33.1*
MCV-97 MCH-31.6 MCHC-32.6 RDW-13.4 Plt Ct-221
[**2182-1-21**] 06:46PM BLOOD PT-14.3* PTT-26.7 INR(PT)-1.2*
[**2182-1-21**] 06:46PM BLOOD Glucose-135* UreaN-14 Creat-1.1 Na-147*
K-3.8 Cl-105 HCO3-30 AnGap-16
[**2182-1-21**] 06:46PM BLOOD CK(CPK)-115
[**2182-1-21**] 06:46PM BLOOD CK-MB-2 cTropnT-0.04*
[**2182-1-21**] 06:46PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8

[**2182-1-22**]
Cardiac Catheterization: Selective coronary angiography in this
right-dominant system demonstrated native three-vessel disease.
The LMCA was occluded distally. The RCA had a proximal total
occlusion.
2. Arterial conduit angiography revealed the LIMA->LAD to have
80%
in-stent restenosis at the anastamosis.
3. Venous conduit angigoraphy revealed the SVG->diagonal branch
to be
widely patent. The SVG->OM1 had 80% in-stent restenosis.
4. Resting hemodynamics revealed elevated left- and right-sided
filling
pressures, with a PCWP of 34 mm Hg and an RA pressure of 12 mm
Hg. There
was moderate pulmonary arterial hypertension with a PASP of 53
mm Hg.
The cardiac index was preserved at 3.1 L/min/m2. The systemic
arterial
blood pressure was normal. There was a 15 mm Hg gradient upon
pullback
of the catheter from the left ventricle to the aorta.
5. Successful PCI of the ostial SVG-OM in-stent restenosis with
a
3.0x15mm Promus DES, post-dilated to 3.25mm.
6. Successful closure of the right femoral arteriotomy site with
a 6F
Angioseal device.
FINAL DIAGNOSIS:
1. Three-vessel native coronary artery disease.
2. Patent SVG->diagonal.
3. In-stent restenosis of the ostial SVG->OM stent and LIMA->LAD
anastamotic stent.
4. Severely elevated left- and right-sided filling pressures.
5. Moderate pulmonary arterial hypertension.
6. Successful PCI of the SVG-OM with DES.

[**2182-1-23**] TTE: The left atrium is moderately dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is moderate global left ventricular hypokinesis (LVEF = 30-35
%). The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with moderate global hypokinesis. Mild aortic valve
stenosis. Moderate mitral regurgitation.

[**2182-1-25**] CCATH: 1. Successful PCI of the LIMA-LAD ISR with a
2.5x15mm Promus DES. 2. Successful closure of the left femoral
arteriotomy site with a 8F Angioseal device. FINAL DIAGNOSIS: 1.
Successful PCI of the LIMA-LAD with DES.

[**2182-1-31**] CXR: As compared to the previous radiograph, the
nasogastric tube has been removed. The left-sided intravenous
access line is in unchanged
position. Unchanged size of the cardiac silhouette, minimal
increase in
extent of the retrocardiac opacity caused by atelectasis.
Otherwise, no
relevant change. No newly occurred focal parenchymal opacities.
No
indication of pulmonary edema.


Brief Hospital Course:
82 year-old male with history of CABG, DM, EtOH abuse,
transfered for cardiac catheterization s/p stent to DES to
LIMA-LAD, course complicated by respiratory failure requiring
intubation.

#. Coronary artery disease:
The patient had symptoms concerning for unstable angina and
presented to an OSH. At that time he had a slight increase in
cardiac enzymes. There were no EKGs from the outside hospital.
The patient was maintained on aspirin, heparin gtt, high-dose
atorvastatin, plavix and metoprolol tartrate. He had a cardiac
catheterization the morning of admission finding in-stent
restenosis of ostial SVG->OM stent and LIMA->LAD. The patient
had a DES in the SVG-OM. The patient developed agitation in the
cath suite and was transfered to the cardiac ICU for further
monitoring. It was thought to be secondary to a paradoxical
effect of the benzos he was given during the procedure. He was
resent to the Cath lab and had a successful PCI of the LIMA-LAD
with DES.  The patient was discharged on metoprolol tartrate,
lisinopril, atorvastatin, aspirin and plavix. He had one episode
of chest pain without EKG changes or cardiac enzyme elevations.
He received 1mg of morphine which relieved his pain. He was
hemodynamically stable at discharge. He should follow up with an
outpatient cardiologist within 2 weeks of discharge.

#. Acute on chronic systolic heart failure and respiratory
failure:
A TTE was done which showed decreased EF of 30-35%. The patient
was intubated for hypoxemic respiratory failure. He was diuresed
and quickly extubated to a BiPAP. He was quickly weaned to face
mask and then 3L NC. He receieved an 8 day course of vancomycin
and cefepime for ventilator associated pneumonia. He was weaned
slowly off of oxygen and had no oxygen requirement upon
discharge. The patient was discharged on diuretics with
torsemide 30 mg daily.

#. Delirium:
The patient initially had both hypoactive and hyperactive
delirium; hypoactive delirium resolved, but hyperactive delirium
at night persisted for weeks with gradual resolution.  Initially
it was thought to be secondary to paradoxical effect of benzos.
Usual precautions were done including minimizing lines, frequent
orientation, etc.  The patient was started on large standing
[**Month/Day/Year 4319**] of seroquel in the evening with an additional smaller
morning [**Month/Day/Year 4319**]. His QTc was not prolonged. He was followed by
both geriatrics and psychiatry throughout his hospitalization.
Despite an improvement in delirium the patient had persistent
difficulty with behavioral control. Despite aggressive medical
management the patient had continued difficulty. He was started
on trazadone and seroquel with some improvement. His dose was
changed to seroquel 25mg qAM, 100mg qHS and 25mg given at midday
to attempt to prevent increased agitation in the late afternoon.
He continues on trazodone 50mg qHS. Per psychiatry, pt should be
wslowly weaned off the Seroquel but discontinuing the day time
dose in about 2 weeks, then decrease the bedtime dose by 25 mg
per week until off.
.
#. Sinus tachycardia:
The patient had sinus tachycardia. He was evaluated for
potential pathological causes and none were found. The likely
etiology was volume depletion and agitation. As the patient's
delirium improved the tachycardia improved.

#. Nutrition:
The patient required an NG tube for medications and tube feeds
while in the ICU. The tube was removed and he was able to eat
and take medications by mouth. Speech and swallow evaluated the
patient was cleared for a full diet with supervision.

#. Diabetes mellitus:
The patient was continued on insulin NPH at bedtime and in the
morning as well as an insulin sliding scale.

#. EtOH abuse:
He was initially monitored on valium per CIWA scale. A social
work consult was ordered. The patient showed no signs of
withdrawal.

#. Hyperlipidemia: continued statin per above.

#. Hypertension: continued medications per above.

#. GERD: changed to H2 blocker from PPI as patient is now on
plavix.

#. Code:  full code for this hospitalization.


Medications on Admission:
CURRENT MEDICATIONS:
Home medications ([**First Name8 (NamePattern2) **] [**Hospital **] Hospital which had contact[**Name (NI) **] CVS)
[**Name (NI) 28865**] 4mg daily
Ativan 1mg [**Hospital1 **] prn
Metolazone 2.5 mg twice a week
Insulin, 52U [**Hospital1 **] per patient
?Spironolactone 25mg daily not refilled since [**9-5**]
ASA
Plavix
Gabapentin 600mg QHS
.
Medications on transfer:
Prilosec 40mg daily
Heparin SC 5000U TID
Insulin NPH 20U [**Hospital1 **] before meals
Insulin s/s: 131-180 4 U, 181-240 8U, 241-300 10U, 301-350 12U,
351-400 16U
Robitussin syrup
MOM 30ml daily
Senokot prn
Tyelnol 650mg Q4H
Nitrostat 0.4mg prn
Mucomyst [**Hospital1 **]
ASA 81mg daily
Lipitor 80mg daily
OscalD 500mg [**Hospital1 **]
Plavix 75mg daily
Lasix 40mg daily
Neurontin 600mg daily HS
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
MVI

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not stop medicine or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] for at least one
year.
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Torsemide 10 mg Tablet Sig: Three (3) Tablet PO once a day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO twice a day as needed for constipation.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-29**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as
needed for wheezing, SOB.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for wheezing, SOB.
13. Senna 8.6 mg Capsule Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for redness in groin area.
15. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
17. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
18. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
19. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO 1600 ().
20. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
21. Humalog 100 unit/mL Solution Sig: as per sliding scale
Subcutaneous four times a day.
22. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Eight (28) units Subcutaneous before breakfast with Humalog.
23. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous before dinner with Humalog.


Discharge Disposition:
Home With Service

Facility:
VNS of Greater [**Doctor Last Name **]

Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Acute Delerium
diabetes Mellitus
Hypertension


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


Discharge Instructions:
You were admitted to the hospital because you had a heart
attack. You received a drug eluting stent to one of your
coronary arteries. It is extremely important that you take
Plavix and aspirin every day for at least one year. Do not stop
taking Plavix or aspirin unless Dr. [**Last Name (STitle) 2912**] tells you to.
You then became delerious and have been improving slowly, we
have started new medicines to help you stay calm and oriented.
.
Your heart function is weaker after the heart attack and you
will need to take new medicines to help it pump better.

You were treated also for a pneumonia with antibiotics.

Weigh yourself every morning, call Dr. [**Last Name (STitle) 28866**] if weight goes
up more than 3 lbs in 1 day or 6 pounds in 3 days once you are
home.
.
Medicaton changes:
1. Stop taking Pravastatin, Lorazepam, spironolactone,
bumetanide, Klor con, Gabapentin, garlic, twice daily metoprolol
and metolazone
2. Increase your aspirin to 325 mg daily to keep the stent open
3. Start using Clobetasol ointment for your back.
4. Start using Torsemide daily to prevent fluid accumulation in
your lungs
5. Start Seroquel to help you relax and keep your mind sharp.
Your doctor will start tapering this medicine slowly in about 2
weeks.
6. Start taking Simvastatin to lower your cholesterol
7. Take the long acting Metoprolol to control your heart rate
8. Start taking Trazadone to help you sleep at night.

Followup Instructions:
Please be sure to keep all of your followup appointments.
.
Primary Care:
[**Last Name (un) 28867**],IQUBAL S Phone: [**Telephone/Fax (1) 28868**] Date/time: Friday [**2-22**] at 1:00pm.
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2182-3-4**] 2:30
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **] C. Phone: [**Telephone/Fax (1) 8543**] Date/Time: [**3-11**]
at 1:15pm.
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Coronary atherosclerosis of autologous vein bypass graft,Other complications due to other cardiac device, implant, and graft,Alcohol withdrawal delirium,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,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 other specified places,Acute alcoholic intoxication in alcoholism, continuous,Dysthymic disorder,Other chronic pulmonary heart diseases,Other specified cardiac dysrhythmias,Mitral valve insufficiency and aortic valve stenosis,Altered mental status'}


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: CP; transfer for cardiac catheterization

PRESENT ILLNESS: 82 yo with hx of DM, CAD s/p CABG [**2152**] redo [**10/2171**], CHF (EF 51%)
admitted to [**Hospital **] Hospital on [**1-7**] with CP. His course was
complicated by DTs [**1-29**] etoh w/d and he was intubated in the ICU.
He was in normal healthy until the am of [**1-7**] when he
experienced [**7-6**] substernal CP which was "squeezing" while
watching TV.  It lasted for 30 minutes without associated
radiation, SOB, nausea, diaphoresis, palpitations or
lightheadedness.  He did not take medications for this incident.
 After dinner he lies down normally for approx 1/2 hour but has
noticed SOB when supine over the past week.  He has gained 30
lbs over the last year.  He has had CP approximately 1X/year for
which he usually takes Nitro.

MEDICAL HISTORY: - CAD s/p cabg [**2152**] with redo in [**10/2171**] at [**Hospital1 18**] see OMR for
complete graft information.
- [**2171**]: stent
- Diabetes diagnosed in [**2152**]
- CHF with EF 55%
- Hypercholesterolanemia
- ETOH abuse drinks a pint of whiskey a day DT's in the past
- Multiple falls
- GERD
- Anxiety/depression
- Obesity
- TIA [**2161**]
.
TTE: EF 55% 7/05

MEDICATION ON ADMISSION: CURRENT MEDICATIONS:
Home medications ([**First Name8 (NamePattern2) **] [**Hospital **] Hospital which had contact[**Name (NI) **] CVS)
[**Name (NI) 28865**] 4mg daily
Ativan 1mg [**Hospital1 **] prn
Metolazone 2.5 mg twice a week
Insulin, 52U [**Hospital1 **] per patient
?Spironolactone 25mg daily not refilled since [**9-5**]
ASA
Plavix
Gabapentin 600mg QHS
.
Medications on transfer:
Prilosec 40mg daily
Heparin SC 5000U TID
Insulin NPH 20U [**Hospital1 **] before meals
Insulin s/s: 131-180 4 U, 181-240 8U, 241-300 10U, 301-350 12U,
351-400 16U
Robitussin syrup
MOM 30ml daily
Senokot prn
Tyelnol 650mg Q4H
Nitrostat 0.4mg prn
Mucomyst [**Hospital1 **]
ASA 81mg daily
Lipitor 80mg daily
OscalD 500mg [**Hospital1 **]
Plavix 75mg daily
Lasix 40mg daily
Neurontin 600mg daily HS
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS -  98.1, 126/64, 18, 94%/RA
Gen: NAD. Oriented x3. Mood appropriate, affect inpatient and
axious.
HEENT: PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa.
Neck: unable to assess JVP.
CV: RR, normal S1, 2/6 SEM. No S3 or S4.
Chest: Resp were unlabored, no accessory muscle use. Shallow BS.
Abd: Soft, NTND. No HSM or tenderness. No femoral bruits.
Ext: 2+ b/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. 2+ DPs
Skin: significant erythema (chronic) anterior left shin; SCV
line on right NT without erythema

FAMILY HISTORY: Father died at 47 of CAD, Mother died at 73 of CAD.

SOCIAL HISTORY: Married with supportive wife who helps with medications.
tob: quit [**2150**]
etoh: 1 pint whiskey/day.  Has had hospitalization for w/d in
the past 

### Response:
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute on chronic systolic heart failure,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Coronary atherosclerosis of autologous vein bypass graft,Other complications due to other cardiac device, implant, and graft,Alcohol withdrawal delirium,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,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 other specified places,Acute alcoholic intoxication in alcoholism, continuous,Dysthymic disorder,Other chronic pulmonary heart diseases,Other specified cardiac dysrhythmias,Mitral valve insufficiency and aortic valve stenosis,Altered mental status'}
