CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: Mr. [**Known lastname 89204**] is a 48yoM with history of CAD, cryptogenic
cirrhosis, diabetes, hypertension, hyperlipidemia and chronic
anemia and [**Hospital 89205**] transferred from OSH for NSTEMI. The
patient states that his symptoms began 3 weeks ago, when he
noticed worsening DOE. Previously, he was able to walk 18 holes
of golf without any CP/SOB. Over the past 3 weeks, he has only
been able to walk 300 feet before he experiences CP/SOB. He
describes the pain as sub-sternal "tightness/burning" with
radiation to the jaw. The pain is [**6-30**] in severity and
assocaited with weakness and lightheadedness. Denies associated
N/V, diaphoresis or palpitations. He came to the hospital this
morning because he expereicned the worst chest pain he has ever
had while removing luggage from the overhead bin on a flight
from [**State 108**]. He prompty sat down, and the pain resolved within
2 minutes. He states that the pain he has had over the past 3
weeks is reliably relieved by rest and states he has ever had
CP/SOB at rest. He has 2 pillow orthopnea with is unchanged over
the past several years. He has also had a non-producitve cough
for the past few weeks.
.
Patient was last at [**Hospital1 **] in [**5-/2102**] for work-up of stable angina.
He had a non-diagnostic stress test (TWI and ST depressions in
lateral leads, did not achieve goal HR, nuc negative) at that
time and was transferred for possible cardiac catheterization.
Given bleeding risk with known varices, thrombocytopenia, and
chronic kidney disease, patient instead underwent coronary CT,
which showed significant calcification throughout all of his
coronary arteries, with probable significant narrowing of the
LCx and OM. As he had no chest pain, enzyme elevations, or
abnormalities on [**Hospital **] medical management was preferred over PCI.
During this admission, he also had a HCT of 24.8 (baseline 30)
and guaiac positive stool. The hepatology team was consulted to
comment on his risk of bleeding if he were to start dual
anti-platelet therapy. An endoscopy showed a pair of duodenal
polyps, of which one was actively oozing blood.
.
At the OSH, he had a troponin I of 4.[**Street Address(2) 89206**]
depressions and a HCT 21. Guiac was negative. He received ASA
325 and 1U pRBCs and was transferred to [**Hospital1 **] for possible cath.
.
In the ED, initial VS: 98.2 75 139/73 18 96% 4L Nasal Cannula.
Patient denied chest pain, nausea, vomiting, back or arm pain.
His labs were significant for troponin of 0.68 and HCT of 26.3.
Exam was significant for bibasilar crackles. Patient received
gabapentin 300 mg x1 (home medication that he wanted to take).
Patient was ordered 1 unit PRBC and was given lasix 10 mg IV x1
with the blood. On transfer vitals were 98.4, 72, 128/62, 24,
100 on 4L.
.
Currently, VS are:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
Denies CP/SOB, arm/back pain, N/V, lightheadedness, diaphoresis.

MEDICAL HISTORY: MEDICAL & SURGICAL HISTORY:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- CAD diagnosed on [**5-/2102**] coronary CT scan
- renal insufficiency
- cyptogenic cirrhosis
- esophageal varices s/p banding
- HTN
- UGIB
- peripheral neuropathy [**2-22**] DM
- Gout
- HLD

MEDICATION ON ADMISSION: Mirapex 0.25 mg qHS
Colchicine 0.6 mg daily
Glyburide-metformin 5-500 mg PO daily
Diovan 320 mg daily
Allopurinol 300 mg daily
Lisinopril 30 mg [**Hospital1 **]
Aranesp injection
Cholecalciferol 1000 units daily
Lantus 40 units daily
Byetta 0.04 mL injection [**Hospital1 **]
Gabapentin 300 mg qHS
Bumetanide 1 mg PO BID
Pravastatin 10 mg daily
Amlodipine 5 mg daily
Pantoprazole 40 mg daily
Nitroglycerin PRN
Nadolol 40 mg daily
Aspirin 81 mg daily
Humalog sliding scale
Fish oil 1000 mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 15cm above the RA, no carotid
bruits
LUNGS - Bibasilar crackels, no increaed WOB. Scattered wheezes.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: DM
- Father: DM, CABG at 65 yo

SOCIAL HISTORY: married with 3 children. lives in [**Location **]. works as a CAD
designer for an engineering firm.
- Tobacco history: quit 5 yrs ago
- ETOH: none
- Illicit drugs: none
Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Portal hypertension,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary complications, not elsewhere classified,Polyneuropathy in diabetes,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Eosinophilia,Epistaxis,Long-term (current) use of insulin,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use
Subendo infarct, initial,Ac kidny fail, tubr necr,Thrombocytopenia NOS,CHF NOS,Ac posthemorrhag anemia,Esoph varice oth dis NOS,Portal hypertension,Hyposmolality,Crnry athrscl natve vssl,Chr blood loss anemia,Cirrhosis of liver NOS,DMII renal uncntrld,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Surg compl-urinary tract,Neuropathy in diabetes,Angio stm/dudn w/o hmrhg,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Eosinophilia,Epistaxis,Long-term use of insulin,Abn react-anastom/graft,Adv eff anticoagulants
Admission Date:  [**2102-11-16**]              Discharge Date:   [**2102-12-2**]

Date of Birth:  [**2053-10-1**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
[**2102-11-27**] - Urgent coronary artery bypass graft x5 with left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal, obtuse marginal and
sequential saphenous vein grafts to posterior descending artery
and posterior left ventricular branch.

History of Present Illness:
Mr. [**Known lastname 89204**] is a 48yoM with history of CAD, cryptogenic
cirrhosis, diabetes, hypertension, hyperlipidemia and chronic
anemia and [**Hospital 89205**] transferred from OSH for NSTEMI. The
patient states that his symptoms began 3 weeks ago, when he
noticed worsening DOE. Previously, he was able to walk 18 holes
of golf without any CP/SOB. Over the past 3 weeks, he has only
been able to walk 300 feet before he experiences CP/SOB. He
describes the pain as sub-sternal "tightness/burning" with
radiation to the jaw. The pain is [**6-30**] in severity and
assocaited with weakness and lightheadedness. Denies associated
N/V, diaphoresis or palpitations. He came to the hospital this
morning because he expereicned the worst chest pain he has ever
had while removing luggage from the overhead bin on a flight
from [**State 108**]. He prompty sat down, and the pain resolved within
2 minutes. He states that the pain he has had over the past 3
weeks is reliably relieved by rest and states he has ever had
CP/SOB at rest. He has 2 pillow orthopnea with is unchanged over
the past several years. He has also had a non-producitve cough
for the past few weeks.
.
Patient was last at [**Hospital1 **] in [**5-/2102**] for work-up of stable angina.
He had a non-diagnostic stress test (TWI and ST depressions in
lateral leads, did not achieve goal HR, nuc negative) at that
time and was transferred for possible cardiac catheterization.
Given bleeding risk with known varices, thrombocytopenia, and
chronic kidney disease, patient instead underwent coronary CT,
which showed significant calcification throughout all of his
coronary arteries, with probable significant narrowing of the
LCx and OM. As he had no chest pain, enzyme elevations, or
abnormalities on [**Hospital **] medical management was preferred over PCI.
During this admission, he also had a HCT of 24.8 (baseline 30)
and guaiac positive stool. The hepatology team was consulted to
comment on his risk of bleeding if he were to start dual
anti-platelet therapy. An endoscopy showed a pair of duodenal
polyps, of which one was actively oozing blood.
.
At the OSH, he had a troponin I of 4.[**Street Address(2) 89206**]
depressions and a HCT 21. Guiac was negative. He received ASA
325 and 1U pRBCs and was transferred to [**Hospital1 **] for possible cath.
.
In the ED, initial VS: 98.2 75 139/73 18 96% 4L Nasal Cannula.
Patient denied chest pain, nausea, vomiting, back or arm pain.
His labs were significant for troponin of 0.68 and HCT of 26.3.
Exam was significant for bibasilar crackles. Patient received
gabapentin 300 mg x1 (home medication that he wanted to take).
Patient was ordered 1 unit PRBC and was given lasix 10 mg IV x1
with the blood. On transfer vitals were 98.4, 72, 128/62, 24,
100 on 4L.
.
Currently, VS are:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
Denies CP/SOB, arm/back pain, N/V, lightheadedness, diaphoresis.


Past Medical History:
MEDICAL & SURGICAL HISTORY:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- CAD diagnosed on [**5-/2102**] coronary CT scan
- renal insufficiency
- cyptogenic cirrhosis
- esophageal varices s/p banding
- HTN
- UGIB
- peripheral neuropathy [**2-22**] DM
- Gout
- HLD


Social History:
married with 3 children. lives in [**Location **]. works as a CAD
designer for an engineering firm.
- Tobacco history: quit 5 yrs ago
- ETOH: none
- Illicit drugs: none


Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: DM
- Father: DM, CABG at 65 yo

Physical Exam:
Admission Exam:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 15cm above the RA, no carotid
bruits
LUNGS - Bibasilar crackels, no increaed WOB. Scattered wheezes.

HEART - PMI non-displaced, RRR, no MRG, loud P2 heard at the
LUSB, no S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, trace BLE edema to the ankle, 2+ peripheral
pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-25**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.



Pertinent Results:
Admission Labs:

[**2102-11-16**] 02:45AM BLOOD WBC-6.0 RBC-3.48*# Hgb-7.6*# Hct-26.3*
MCV-76* MCH-21.8* MCHC-28.9* RDW-16.0* Plt Ct-63*
[**2102-11-16**] 02:45AM BLOOD Neuts-50 Bands-0 Lymphs-32 Monos-3
Eos-15* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2102-11-16**] 02:45AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-2+ Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2102-11-16**] 02:45AM BLOOD PT-11.7 PTT-22.0 INR(PT)-1.0
[**2102-11-16**] 02:45AM BLOOD Glucose-227* UreaN-28* Creat-1.6* Na-138
K-3.5 Cl-106 HCO3-23 AnGap-13
[**2102-11-16**] 02:45AM BLOOD ALT-54* AST-60* CK(CPK)-254 AlkPhos-121
TotBili-0.4
[**2102-11-16**] 02:45AM BLOOD Lipase-142*
[**2102-11-16**] 02:45AM BLOOD CK-MB-15* MB Indx-5.9
[**2102-11-16**] 02:45AM BLOOD cTropnT-0.68*
[**2102-11-16**] 09:00AM BLOOD CK-MB-11* cTropnT-0.75*
[**2102-11-17**] 07:40AM BLOOD CK-MB-3 cTropnT-0.57*
[**2102-11-16**] 02:45AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8
[**2102-11-16**] 02:45AM BLOOD Hapto-55
[**2102-11-17**] 07:40AM BLOOD %HbA1c-6.3* eAG-134*
[**2102-11-17**] 07:40AM BLOOD AFP-2.1
.
Studies:
TTE ([**2102-11-16**]):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is low
normal (LVEF 50%) secondary to hypokinesis of the anterior
septum, anterior free wall, and apex. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. 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 no
pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2102-6-13**], anterior and apical hypokinesis are now present.

.
Cardiac Cath ([**2102-11-17**]):
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel CAD. The LMCA was patent.  The LAD had
a 40%
proximal stenosis and a 90% mid vessel stenosis. The LCx had
diffuse
disease up to 60% with a 70% stenosis in a major OM branch. The
RCA had
a 95% stenosis in both large PL branches.
2. Limited resting hemodynamics revealed normal systemic
arterial
systolic pressures with an SBP of 121 mmHg.

FINAL DIAGNOSIS:
1. Three vessel CAD.
2. Normal systemic blood pressure.
.
Abd Ulatrsound ([**2102-11-17**]):
FINDINGS: The hepatic architecture is unremarkable. No focal
liver lesion is identified. No biliary dilatation is seen. The
gallbladder is contracted as the patient ate prior to the
ultrasound. A small shadowing stone is seen at the neck of the
gallbladder. The pancreas and aorta are obscured from view by
overlying bowel. The spleen is enlarged measuring 14.4 cm. No
hydronephrosis is seen. The visualized portion of the IVC is
unremarkable. There is a small right and a small left pleural
effusion. No ascites is seen in the abdomen.

DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. The main, right and left portal veins are patent with
hepatopetal flow. Appropriate flow is seen in the hepatic veins,
SMV, and IVC. Appropriate arterial waveforms are seen in the
main hepatic artery.

IMPRESSION:
1. No focal liver lesion.
2. Patent hepatic vasculature.
3. Splenomegaly.
4. Cholelithiasis.
5. No ascites identified.
.
CXR (PA/LAT [**2102-11-17**]):
FINDINGS: In comparison with study of [**11-16**], even allowing for
the PA
projection, there appears to be improvement in the cardiac
silhouette and
degree of pulmonary vascular congestion. No acute focal
pneumonia or definite pleural effusion.
.

Brief Hospital Course:
Primary Reason for Admission: Mr. [**Known lastname 89204**] is a 49 year-old male
with history of CAD, cryptogenic cirrhosis, diabetes,
hypertension, hyperlipidemia transferred from OSH for NSTEMI.
Below are his major issues categorized and that is followed by
his hospital course starting with his cardiac surgery.
.
Active Problems:
.
# NSTEMI: Pt ruled in with positive troponins/CKMB in the
setting of exertional CP. Favor type II NSTEMI given angina only
occurs with exertion and never occurs at rest. He underwent
cardiac cath that showed 3VD (see report). No stents were placed
and the patient was placed on a Heparin gtt, ASA 325 and
Atorvastatin 80mg while being evaluated by cardiac surgery for
CABG. Cardiac surgery felt the patient was a good CABG candidate
pending Hematololgy (thrombocytopenia) and Liver (cirrhosis)
recs and risk stratification. The patient's Heparin was
continued for 3 days and stopped on [**2102-11-19**] due to a nose bleed
with a HCT drop from 31->26. He was continued on ASA 325 and his
home Carvedilol was increased from 6.25 [**Hospital1 **]. His home Bumex and
Lisinorpil are being held untillhe f/u with his PCP. [**Name10 (NameIs) **] PCP
will adjust medications accordingly.
.
# Anemia: Pt with known esophageal and gastric varicies,
recently s/p banding of a single varix at [**Hospital1 **] (7/[**2102**]). No
known h/o variceal bleeding. On admission stools were guiac
negative. However, s/p nosebleed in the setting of Heparin gtt,
pt's stools turned guiac positive and his heparin was stopped
after 72 hours. Pt was transfused 2U pRBCs on admission for HCT
<30 in the setting of active ischemia with good response. He was
transfused 1U pRBCs for HCT 31->26 in the setting of nose bleed
with excellent response 26->33. Decision was made to pursue EGD
to ensure no variceal bleeding and minimize operative bleeding
risk. EGD on [**2102-11-22**] showed non bleeding grade [**1-22**] esophageal
varicies and gastric/duodenal AVMs that were cauterized. He was
stratified as low risk for bleeding by GI.
.
# DM: Pt's A1C was 6.3% on admission, though this is in the
setting of 2U pRBC transfusion. As such, he is likely not as
well controlled as his A1C would suggest. Oral agents were held
throughout his course and he was given his home 40U Lantus qam
and started on ISS. His BG was poorly controlled initially and
his Lantus and ISS were uptitrated. On [**2102-11-21**] [**Last Name (un) **] was
consulted for persistent hyperglycemia (300-400s) despite 3 days
of escalating Lantus/ISS. [**Last Name (un) **] recommended increasing Lantus
to 35U qam and 35U qhs with supplemental ISS. Thereafter his BG
control was improved, with BG in the 90-100s.
.
Chronic Problems:
.
# Crypotgenic Cirrhosis: Pts LFTs remained stable throughout his
course, he was continued on his home meds. Hepatology was
consulted and felt the pt was low risk for bleeding from his
varicies during CABG.
.
# Thrombocytopenia: Chronic; heme was consulted and recommended
platelet transfusion pre, intra and post-operatively with goal
platelets >100,000.
.
Mr. [**Name13 (STitle) 32245**] was taken to the the operating room on [**2102-11-27**] where
he underwent coronary artery bypass grafting to five vessels.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. He was
transfused with fresh frozen plasma and red blood cells for
postoperative anemia and thrombocytopenia. On postoperative day
one, Mr. [**Known lastname 89204**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
The renal and hematology service continued to follow him
closely. His creatinine trended upward following surgery likely
due to hypoperfusion or acute tubular necrosis related to
surgery. His renal function eventually stabilized. The [**Last Name (un) 387**]
diabetes service was consulted for assistance with his diabetes
medication management. On postoperative day three, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility.

Mr. [**Known lastname 89204**] continued to make steady progress and was
discharged home on postoperative day 5 Appointments have been
made for him to follow-up with Dr. [**First Name (STitle) **], his cardiologist and
his primary care physician as an outpatient.

Medications on Admission:
Mirapex 0.25 mg qHS
Colchicine 0.6 mg daily
Glyburide-metformin 5-500 mg PO daily
Diovan 320 mg daily
Allopurinol 300 mg daily
Lisinopril 30 mg [**Hospital1 **]
Aranesp injection
Cholecalciferol 1000 units daily
Lantus 40 units daily
Byetta 0.04 mL injection [**Hospital1 **]
Gabapentin 300 mg qHS
Bumetanide 1 mg PO BID
Pravastatin 10 mg daily
Amlodipine 5 mg daily
Pantoprazole 40 mg daily
Nitroglycerin PRN
Nadolol 40 mg daily
Aspirin 81 mg daily
Humalog sliding scale
Fish oil 1000 mg [**Hospital1 **]


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
NSTEMI
noninsulin dependent Diabetes mellitus
Dyslipidemia
Hypertension
coronary artery disease
s/p coronary artery bypass grafts
renal insufficiency
cryptogenic cirrhosis
esophageal varices s/p banding
h/o gastrointestinal bleeds
diabetic neuropathy
Gout
Restless Leg Syndrome
Sleep Apnea (uses CPAP)
thrombocytopenia
Chronic anemia


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


Discharge Instructions:
Dear Mr [**Known lastname 89204**],

It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for chest pain. We performed
several tests and found that your pain was due to a small heart
attack. For this, we perofrmed a cardiac catheterization, which
showed mulitple coronary arteries with cholesterol deposits,
which is the cause of your heart attack. The best treatment for
this is surgery, and therefore we placed you on blood thinners
for your heart attack and had the surgeons evaluate you.

After a thorough pre-operative evaluation, we feel you are safe
for surgery and safe to return home. The surgeons will be in
contact with you regarding a date for your operation.

During this hospitaliztion, we made the following changes to
your medications:
STARTED Carvedilol to 25mg by mouth twice a day
CHANGED Allopurinol to 150mg by mouth once a day
STOPPED Nadolol 40mg by mouth once a day

Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr.[**First Name (STitle) **]([**Telephone/Fax (1) 170**]on [**2103-1-2**] at 1pm in the [**Hospital **]
Medical Office Building, [**Last Name (NamePattern1) **]., [**Hospital Unit Name **]. Wound check
in the same locale on [**2102-12-12**] at 10:15am

Cardiologist:Dr. [**Last Name (STitle) 10543**] on [**2102-12-28**] at 2pm

Please call to schedule appointments with your
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 53156**]) in [**4-25**] weeks

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**



                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2102-12-2**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Portal hypertension,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary complications, not elsewhere classified,Polyneuropathy in diabetes,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Eosinophilia,Epistaxis,Long-term (current) use of insulin,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use'}


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: Mr. [**Known lastname 89204**] is a 48yoM with history of CAD, cryptogenic
cirrhosis, diabetes, hypertension, hyperlipidemia and chronic
anemia and [**Hospital 89205**] transferred from OSH for NSTEMI. The
patient states that his symptoms began 3 weeks ago, when he
noticed worsening DOE. Previously, he was able to walk 18 holes
of golf without any CP/SOB. Over the past 3 weeks, he has only
been able to walk 300 feet before he experiences CP/SOB. He
describes the pain as sub-sternal "tightness/burning" with
radiation to the jaw. The pain is [**6-30**] in severity and
assocaited with weakness and lightheadedness. Denies associated
N/V, diaphoresis or palpitations. He came to the hospital this
morning because he expereicned the worst chest pain he has ever
had while removing luggage from the overhead bin on a flight
from [**State 108**]. He prompty sat down, and the pain resolved within
2 minutes. He states that the pain he has had over the past 3
weeks is reliably relieved by rest and states he has ever had
CP/SOB at rest. He has 2 pillow orthopnea with is unchanged over
the past several years. He has also had a non-producitve cough
for the past few weeks.
.
Patient was last at [**Hospital1 **] in [**5-/2102**] for work-up of stable angina.
He had a non-diagnostic stress test (TWI and ST depressions in
lateral leads, did not achieve goal HR, nuc negative) at that
time and was transferred for possible cardiac catheterization.
Given bleeding risk with known varices, thrombocytopenia, and
chronic kidney disease, patient instead underwent coronary CT,
which showed significant calcification throughout all of his
coronary arteries, with probable significant narrowing of the
LCx and OM. As he had no chest pain, enzyme elevations, or
abnormalities on [**Hospital **] medical management was preferred over PCI.
During this admission, he also had a HCT of 24.8 (baseline 30)
and guaiac positive stool. The hepatology team was consulted to
comment on his risk of bleeding if he were to start dual
anti-platelet therapy. An endoscopy showed a pair of duodenal
polyps, of which one was actively oozing blood.
.
At the OSH, he had a troponin I of 4.[**Street Address(2) 89206**]
depressions and a HCT 21. Guiac was negative. He received ASA
325 and 1U pRBCs and was transferred to [**Hospital1 **] for possible cath.
.
In the ED, initial VS: 98.2 75 139/73 18 96% 4L Nasal Cannula.
Patient denied chest pain, nausea, vomiting, back or arm pain.
His labs were significant for troponin of 0.68 and HCT of 26.3.
Exam was significant for bibasilar crackles. Patient received
gabapentin 300 mg x1 (home medication that he wanted to take).
Patient was ordered 1 unit PRBC and was given lasix 10 mg IV x1
with the blood. On transfer vitals were 98.4, 72, 128/62, 24,
100 on 4L.
.
Currently, VS are:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
Denies CP/SOB, arm/back pain, N/V, lightheadedness, diaphoresis.

MEDICAL HISTORY: MEDICAL & SURGICAL HISTORY:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- CAD diagnosed on [**5-/2102**] coronary CT scan
- renal insufficiency
- cyptogenic cirrhosis
- esophageal varices s/p banding
- HTN
- UGIB
- peripheral neuropathy [**2-22**] DM
- Gout
- HLD

MEDICATION ON ADMISSION: Mirapex 0.25 mg qHS
Colchicine 0.6 mg daily
Glyburide-metformin 5-500 mg PO daily
Diovan 320 mg daily
Allopurinol 300 mg daily
Lisinopril 30 mg [**Hospital1 **]
Aranesp injection
Cholecalciferol 1000 units daily
Lantus 40 units daily
Byetta 0.04 mL injection [**Hospital1 **]
Gabapentin 300 mg qHS
Bumetanide 1 mg PO BID
Pravastatin 10 mg daily
Amlodipine 5 mg daily
Pantoprazole 40 mg daily
Nitroglycerin PRN
Nadolol 40 mg daily
Aspirin 81 mg daily
Humalog sliding scale
Fish oil 1000 mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
T 98.4 HR 77 BP 132/79 RR 16 O2 Sat 97% 4L NC
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVP 15cm above the RA, no carotid
bruits
LUNGS - Bibasilar crackels, no increaed WOB. Scattered wheezes.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: DM
- Father: DM, CABG at 65 yo

SOCIAL HISTORY: married with 3 children. lives in [**Location **]. works as a CAD
designer for an engineering firm.
- Tobacco history: quit 5 yrs ago
- ETOH: none
- Illicit drugs: none 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Portal hypertension,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Iron deficiency anemia secondary to blood loss (chronic),Cirrhosis of liver without mention of alcohol,Diabetes with renal manifestations, type II or unspecified type, uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary complications, not elsewhere classified,Polyneuropathy in diabetes,Angiodysplasia of stomach and duodenum without mention of hemorrhage,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Eosinophilia,Epistaxis,Long-term (current) use of insulin,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use'}
