CHIEF COMPLAINT: s/p v. fib arrest

PRESENT ILLNESS: 39 y/oM with PMH of HTN, [**Hospital **] transferred from OSH s/p inferior-
lateral STEMI c/b vfib arrest in cardiogenic shock requiring
multiple pressors and intra-aortic balloon pump, on artic sun
protocol.
.
Per family and records, patient complained of intermittent chest
pain, cough, and URI symptoms x 3 days.  Yesterday after getting
home from work, he had worsening chest pressure and went to bed
early.  At 3:15am, wife reports hearing patient fall from bed.
He was found unresponsive with agonal respirations.  When EMS
arrived approx 30min later, patient was found to be in slow VT/
vfib arrest with "fixed and dilated pupils."  CPR was initiated
en route to OSH with shock x 1, epi x 2 and intubation.
.
At OSH, patient was hypotensive with SBP in 70s and EKG showing
STE in inferior-lateral leads.  Emergent cardiac catheterization
showed 100% mid-RCA occlusion, which was stented with [**Hospital **] x2.
He was given ASA 325 mg, a plavix load of 600 mg, 5000 unit
bolus of heparin, and integrillin gtt.  Intra-aortic balloon
pump was placed and started on dopamine and phenylephrine via
PIV for blood pressure support.  Labs prior to transfer were
significant for WBC of 10.8, trop < 0.01, CK 93 with ABG
7.14/40/407/13.  Patient was transferred to [**Hospital1 18**] for further
care with cooling initiated via 2L chilled NS during med flight.
 Med-flight also placed c-collar given report of trauma prior to
episode of unresponsiveness.
.
Upon transfer to CCU, patient intubated, hypothermic and sedate.
 Pupils minimally responsive with absent corneal reflex and
suppressed DTRs.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension

MEDICATION ON ADMISSION: lisinopril 10mg daily
metformin 1000 mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GENERAL: intubated, sedate and hypothermic
HEENT: sclerae anicteric; dried blood around nares
NECK: unable to assess JVP given c-collar
CARDIAC: RRR S1 S2, intra-aortic balloon pump audible throughout
precordium
LUNGS: equal air entry bilaterally
ABDOMEN: soft/ ND/ NABS
EXTREMITIES: no c/c/e
NEURO: sedate, unresponsive.  pupils 3mm and minimally
responsive.  Corneal reflex absent.  Normal tone and bulk.  DTR
difficult to elicit. Toes downgoing b/l
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP dopperable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+

FAMILY HISTORY: Family history uncertain but per wife, no history of early MI or
sudden cardiac death
father: CVA in late 60s

SOCIAL HISTORY: immigrant from [**Country 149**] approx 10 yrs ago.  Currently living with
wife and 2 children aged 10 and 6.
-Tobacco history: none
-ETOH: none, previously drank socially
-Illicit drugs: none
Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Ventricular fibrillation,Acute and subacute necrosis of liver,Acute systolic heart failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Acidosis,Ventilator associated pneumonia,Other and unspecified coagulation defects,Coronary atherosclerosis of native coronary artery,Anticoagulants causing adverse effects in therapeutic use
AMI inferolateral, init,Cardiogenic shock,Ventricular fibrillation,Acute necrosis of liver,Ac systolic hrt failure,Pneumococcal pneumonia,Acute respiratry failure,Acidosis,Ventltr assoc pneumonia,Coagulat defect NEC/NOS,Crnry athrscl natve vssl,Adv eff anticoagulants
Admission Date:  [**2104-3-25**]              Discharge Date:   [**2104-4-4**]

Date of Birth:  [**2064-10-15**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
s/p v. fib arrest

Major Surgical or Invasive Procedure:
Intra aortic balloon pump
right internal jugular central line


History of Present Illness:
39 y/oM with PMH of HTN, [**Hospital **] transferred from OSH s/p inferior-
lateral STEMI c/b vfib arrest in cardiogenic shock requiring
multiple pressors and intra-aortic balloon pump, on artic sun
protocol.
.
Per family and records, patient complained of intermittent chest
pain, cough, and URI symptoms x 3 days.  Yesterday after getting
home from work, he had worsening chest pressure and went to bed
early.  At 3:15am, wife reports hearing patient fall from bed.
He was found unresponsive with agonal respirations.  When EMS
arrived approx 30min later, patient was found to be in slow VT/
vfib arrest with "fixed and dilated pupils."  CPR was initiated
en route to OSH with shock x 1, epi x 2 and intubation.
.
At OSH, patient was hypotensive with SBP in 70s and EKG showing
STE in inferior-lateral leads.  Emergent cardiac catheterization
showed 100% mid-RCA occlusion, which was stented with [**Hospital **] x2.
He was given ASA 325 mg, a plavix load of 600 mg, 5000 unit
bolus of heparin, and integrillin gtt.  Intra-aortic balloon
pump was placed and started on dopamine and phenylephrine via
PIV for blood pressure support.  Labs prior to transfer were
significant for WBC of 10.8, trop < 0.01, CK 93 with ABG
7.14/40/407/13.  Patient was transferred to [**Hospital1 18**] for further
care with cooling initiated via 2L chilled NS during med flight.
 Med-flight also placed c-collar given report of trauma prior to
episode of unresponsiveness.
.
Upon transfer to CCU, patient intubated, hypothermic and sedate.
 Pupils minimally responsive with absent corneal reflex and
suppressed DTRs.

Unable to obtain a rewiew of symptoms as the patient is
intubated.

Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension

Social History:
immigrant from [**Country 149**] approx 10 yrs ago.  Currently living with
wife and 2 children aged 10 and 6.
-Tobacco history: none
-ETOH: none, previously drank socially
-Illicit drugs: none

Family History:
Family history uncertain but per wife, no history of early MI or
sudden cardiac death
father: CVA in late 60s

Physical Exam:
GENERAL: intubated, sedate and hypothermic
HEENT: sclerae anicteric; dried blood around nares
NECK: unable to assess JVP given c-collar
CARDIAC: RRR S1 S2, intra-aortic balloon pump audible throughout
precordium
LUNGS: equal air entry bilaterally
ABDOMEN: soft/ ND/ NABS
EXTREMITIES: no c/c/e
NEURO: sedate, unresponsive.  pupils 3mm and minimally
responsive.  Corneal reflex absent.  Normal tone and bulk.  DTR
difficult to elicit. Toes downgoing b/l
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP dopperable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+

Pertinent Results:
Admission Labs:
[**2104-3-25**] 09:58AM BLOOD WBC-22.2* RBC-4.72 Hgb-13.7* Hct-42.6
MCV-90 MCH-28.9 MCHC-32.1 RDW-12.7 Plt Ct-332
[**2104-3-25**] 09:58AM BLOOD Neuts-87.4* Lymphs-7.6* Monos-4.4 Eos-0.4
Baso-0.3
[**2104-3-25**] 09:58AM BLOOD PT-14.6* PTT-29.5 INR(PT)-1.3*

[**2104-3-25**] 09:58AM BLOOD Glucose-426* UreaN-17 Creat-0.8 Na-142
K-3.8 Cl-111* HCO3-17* AnGap-18
[**2104-3-25**] 03:02PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.6

LFTS
[**2104-3-25**] 09:58AM BLOOD ALT-336* AST-612* LD(LDH)-1072*
CK(CPK)-4978* AlkPhos-70 TotBili-0.5

Cardiac Biomarkers:
[**2104-3-28**] 02:17AM BLOOD CK-MB-76* MB Indx-3.7 cTropnT-2.86*
[**2104-3-27**] 04:53AM BLOOD CK-MB-323* MB Indx-14.2* cTropnT-3.92*
[**2104-3-26**] 11:01PM BLOOD CK-MB-466* MB Indx-16.8*
[**2104-3-26**] 05:02PM BLOOD CK-MB-GREATER TH
[**2104-3-26**] 11:02AM BLOOD CK-MB-GREATER TH
[**2104-3-26**] 03:05AM BLOOD CK-MB-GREATER TH cTropnT-7.71*
[**2104-3-25**] 03:02PM BLOOD CK-MB-GREATER TH cTropnT-10.76*
[**2104-3-25**] 09:58AM BLOOD CK-MB-GREATER TH cTropnT-9.64*

Other:
[**2104-3-29**] 02:23AM BLOOD Hapto-234*
[**2104-3-25**] 09:58AM BLOOD Fibrino-242
[**2104-3-29**] 04:47AM BLOOD Ret Aut-1.8
[**2104-3-25**] 09:58AM BLOOD %HbA1c-7.9* eAG-180*
[**2104-3-25**] 09:58AM BLOOD Triglyc-152* HDL-30 CHOL/HD-4.2
LDLcalc-67
[**2104-3-25**] 03:02PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

ABGs:
[**2104-3-26**] 11:14PM BLOOD Type-ART pO2-99 pCO2-37 pH-7.37
calTCO2-22 Base XS--3
[**2104-3-26**] 06:08PM BLOOD Type-ART Temp-35.9 Rates-/14 Tidal V-550
PEEP-5 FiO2-30 pO2-96 pCO2-37 pH-7.32* calTCO2-20* Base XS--6
-ASSIST/CON Intubat-INTUBATED
[**2104-3-26**] 03:11AM BLOOD Type-ART Temp-32.3 pO2-92 pCO2-28*
pH-7.38 calTCO2-17* Base XS--6
[**2104-3-25**] 10:05PM BLOOD Type-ART pO2-154* pCO2-35 pH-7.31*
calTCO2-18* Base XS--7
[**2104-3-25**] 05:19PM BLOOD Type-ART pO2-202* pCO2-32* pH-7.23*
calTCO2-14* Base XS--13
[**2104-3-25**] 01:57PM BLOOD Type-ART Rates-16/0 Tidal V-550 PEEP-5
FiO2-50 pO2-229* pCO2-38 pH-7.15* calTCO2-14* Base XS--15
-ASSIST/CON Intubat-INTUBATED
[**2104-3-25**] 10:15AM BLOOD Type-ART pO2-330* pCO2-52* pH-7.09*
calTCO2-17* Base XS--14
[**2104-3-26**] 11:18AM BLOOD Lactate-2.6*
[**2104-3-25**] 10:05PM BLOOD Lactate-3.7*
[**2104-3-25**] 05:19PM BLOOD Lactate-4.7*
[**2104-3-25**] 01:57PM BLOOD Glucose-146* Lactate-6.1* Na-146 K-3.1*
[**2104-3-25**] 10:15AM BLOOD Lactate-4.5*

ECG [**2104-3-25**]:
Artifact is present. Sinus rhythm. There are Q waves with ST
segment
elevation in the inferior leads and the anterolateral leads
consistent with acute or evolving infarction. Reciprocal
depressions in the lateral leads offer additional evidence of
ischemia. Clinical correlation is suggested. No previous tracing
available for comparison.

ECHO [**2104-3-25**]:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is severely
depressed (LVEF= 25 %) with inferior/inferolateral/inferoseptal
akinesis and moderate to severe hypokinesis elsewhere.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size is normal. with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. An
eccentric, posteriorly directed jet of Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a very small pericardial effusion.

ECHO [**2104-3-27**]:
There is mild regional left ventricular systolic dysfunction
with inferior and posterior akinesis. The remaining segments
contract normally (LVEF = 40%). Right ventricular chamber size
is normal. with mild global free wall hypokinesis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.

IMPRESSION: No left ventricular pseudoaneurysm or free wall
rupture seen. Mild regional left ventricular systolic
dysfunction, c/w inferoposterior myocardial infarction. Very
small pericardial effusion.

CT Head [**2104-3-29**]:
No acute intracranial hemorrhage, edema, mass effect or large
acute
territorial infarction. [**Doctor Last Name **]-white matter differentiation is
well preserved.  The ventricles and sulci are normal in size and
configuration. There is almost complete opacification of the
ethmoid and maxillary sinuses, with Hounsfield unit measurements
consistent with fluid. There are secretions in the nasopharynx.

IMPRESSION: No acute intracranial process.

C-Spine [**2104-3-29**]:
1. No fracture.
2. Moderate degenerative changes at C5/C6 with posterior disc
osteophyte
complex. The spinal cord cannot be assessed on CT and MRI might
be considered if clinically indicated.
3. Left upper lobe opacity might represent pneumonia.

EEG [**2104-3-26**]:
This is an abnormal video EEG due to the presence of a slow
background which was generally in the delta and theta frequency
range
representing a moderate to severe diffuse encephalopathy. There
were
very brief periods of alpha frequency background. Overall, after
10
p.m. on [**3-26**], the background frequency increased. It is also

abnormal due to the presence of bifrontal delta and theta
frequency
slowing seen representing bifrontal subcortical dysfunction.
Overall,
there was higher amplitude anteriorly which may indicate
bilateral
posterior cerebral dysfunction. There were no epileptiform
discharges
or electrographic seizures.

EEG: [**2104-3-30**]:
This is an abnormal video EEG due to the presence of a slow
background which represents a moderate encephalopathy. There
were brief
periods of normal background frequency. It is also abnormal due
to the
presence of generalized delta frequency slowing which represents
a
diffuse subcortical dysfunction. Overall, this record showed
improved
faster background frequency compared to the previous 24 hours.
There
were no epileptiform discharges or electrographic seizures.
.
Brain MRI [**4-3**]:
FINDINGS: The parenchymal [**Doctor Last Name 352**]-white matter differentiation is
maintained.  There is a small oval-shaped 1.4 x 0.6 cm T2
hyperintense, FLAIR hypointense cystic structure abutting the
right aspect of the superior sagittal sinus at the vertex, which
does not demonstrate restricted diffusion, consistent with small
arachnoid cyst. There is no evidence of infarction, intracranial
hemorrhage, mass (with the exception of the above-mentioned
small arachnoid cyst), mass effect, or shift of midline
structures. The ventricles and sulci are normal in size and
configuration for the patient's age. The major intracranial flow
voids are present. There is moderate mucosal thickening of the
sphenoid sinuses, left greater than right and mucosal thickening
versus
fluid within the mastoid air cells, right greater than left. The
right
maxillary sinus is completely occluded with T2 hyperintense
material, likely mucus secretions.

IMPRESSION:
1. No evidence of acute intracranial abnormality is
demonstrated. No
evidence of infarction identified.
2. Paranasal and mastoid sinus disease described above. The
right maxillary sinus is completely occluded.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]

Labs at discharge:
 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2104-4-4**] 06:23    9.5 4.28* 12.6* 36.4* 85 29.3 34.5 13.7 727*


RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2104-4-4**] 06:23    173*1 18 0.8 142 4.3 104 28 14

Blood culture x2 on [**3-30**] and [**4-4**] are NGTD, urine culture is
pending.


Brief Hospital Course:
Patient is a 39 y/oM with PMH of HTN, [**Hospital **] transferred from OSH
s/p inferior- lateral STEMI and V fib arrest admitted in
cardiogenic shock requiring multiple pressors and intra-aortic
balloon pump, who was on the artic sun protocol, extubated on
[**2104-3-31**] and was discharged to rehab.

# S/P Cardiac arrest: Patient experienced V. Fib cardiac arrest
at home in the setting of inferio-lateral STEMI. He had an
unknown down time and chest compressions were not started before
paramedics arrived. On admission, he was hypotensive [**2-13**] RV
infarct requiring multiple pressors (initially dopamine,
neosynephrine and then dobutamine) and intra-aortic balloon
pump. Elevated lactate on ABG was indicative of ischemia. His
urine output and MAP were monitored and he was given fluid
boluses to keep urine output > 30cc/hr and MAP > 60mmHg. His
initial echo showed severe global hypokinesis with an EF of 25%.
His echo on HD 3 showed EF improved to 40% and no mechanical
complications. He was no longer requiring pressors by HD2 and
his intra-aortic balloon pump was discontinued on [**2104-3-28**]. He
was extubated on [**2104-3-31**]. He showed gradual improvement in his
neurologic exam over the course of his admission.

# CORONARIES: Patient presented with mid-RCA occlusion s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]
2 with return of TIMI 3 flow.  Per cardiac cath report, patient
has no- minimal disease in other coronary arteries. He was
started on heparin drip. He was given integrillin for 18 hrs s/p
intervention. He was also treated with atorvostatin 80 mg,
plavix 75 mg po daily, aspirin 325 mg po daily. He was also
started on ACE inhibitor and beta blocker after resolution of
cardiogenic shock. His metprolol was uptitrated to 300 mg to
control a persistant Sinus tachycardia.

#RHYTHM: Patient was initially found to be in vfib requiring CPR
and cardioversion. He was initially started on amiodarone drip
with junctional rhythm but this was stopped on HD2. He was
monitored on telemetry and remained in sinus rhythm with
occasional PVCs.

#PUMP: Patient had no known hx of CHF. His initial echo showed
EF 25% with global hypokinesis and his repeat echo was much
improved with EF of 40% and improved ventricular function.

# Neuro: The initial EMT evaluation reported "fixed dilated
pupils" and uncertain length of time unresponsive. His initial
neurologic exam in the CCU was difficult given sedation and
paralytics although reactive pupils were reassuring.  He was
cooled and rewarmed per artic sun protocol for neuro protection.
He was also enrolled in the CoEnzyme Q Study. Post-extubation,
his neuro exam continued to improve. He was quite weak but was
able to move all extremities. He was oriented to person,
hospital and year. There are some dystonic movements noted with
intentional movements that are impairing ambulation and acitivty
in small measures. MRI brain revealed no evidence of acute
intracranial abnormality and no
evidence of infarction identified. He was discharged to rehab in
stable condition. He will follow-up with the neurobehavioral
clinic as an outpatient.

# Pneumonia: Patient had 3 days of URI symptoms prior to
admission. On HD3, he had increased secretions and fever. His
pneumonia may have been community acquired, particularly with
his recent URI however, ventilator associated pneumonia was also
possible. He was started on vancomycin and cefepime on [**2104-3-27**].
His sputum grew strep pneumo and his cefepime was changed to
ceftriaxone. His vancomycin was initially continued as he has 1
blood culture bottle that grew GPCs, found to be coag negative
staph, likely contaminant. He continued to spike fevers and his
ceftriaxone was changed to zosyn. He was clinically improved and
he was changed to cefpodoxime which was continued for a 10 day
total course until [**4-5**].

# Metabolic acidosis: On admission, patient had a pH of 7.09
with lactate of 4.5 on arrival to CCU.  STEMI was the most
likely etiology factor but there was also come concern about
lower extremity ischemia from balloon pump or mesenteric
ischemia (esp with guiac + stool). His lactate improved with
improved blood pressures and several amps of HCO3 and he had no
other signs of leg ischemia or mesenteric ischemia.

# Leukocytosis: WBC was 22 on admission likely stress response
from STEMI and cardiogenic shock.  Initially there was no
evidence of infection although he did develop a pneumonia. On
discharge, his CXR is clear and WBC is normal. Occasional low
grade temps with no obvious source.

# Type II DM: Patient was admitted with hyperglycemia to 400s in
the setting of MI. He was started on an insulin drip and his
fingerstick blood glucose levels dropped appropriately. He was
then transitioned to humalog sliding scale. His A1c was 7.6. His
home metformin was held thoughout his hospitalization and was
restarted on discharge.

# Tranaminitis: Was likely [**2-13**] shock liver and muscle injury
from STEMI and CPR. His LFTs fell appropriately thoughout his
hospital course.

Medications on Admission:
lisinopril 10mg daily
metformin 1000 mg [**Hospital1 **]

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): do not stop of miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] for at least one year.
4. multivitamin, stress formula     Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath.
7. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath.
8. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever, pain.
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 1 days.
13. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
14. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous q AC and HS: as per sliding scale.
15. metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Acute Systolic congestive Heart Failure
ST Elevation Myocardial Infarction
Ventricular fibrillation arrest with neurological changes
Hypertension
Diabetes mellitus type 2
Ventilator associated pneumonia


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


Discharge Instructions:
You had a heart attack and collapsed at home. A cardiac
catheterization was performed and you received 2 drug eluting
stents to your right coronary artery. There were no other
significant blockages in your arteries. You underwent a cooling
protocol to help you recover from the event and has slowly had
improvement in your brain and heart function. You will need to
go to a rehabilitation facility to regain your strength and be
monitored closely. Your heart is weaker after the heart attack
and you will need to weigh yourself every morning, call Dr.
[**Last Name (STitle) 171**] if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days.
.
We made the following changes to your medicines:
1. Decrease Lisinopril to 5 mg daily
2. Start metoprolol to lower your heart rate
3. Start atorvastatin to lower your cholesterol
4. Start aspirin 325 mg daily and Plavix 75 mg daily to prevent
the stents from clotting off, do not stop taking aspirin and
plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 171**] tells you to. This
is very important to prevent another heart attack or death.
5. Start senna and colace to prevent constipation
6. Start albuterol and Ipratroprium nebulizers to treat wheezing
as needed
7. Start multivitamin to help your nutrition
8. continue Cefpodoxime to treat your pneumonia
9. Start insulin to treat high blood sugars
10. Start heparin injections to prevent blood clots
11. start tylenol as needed for pain

Followup Instructions:
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2104-5-15**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage
.
Primary Care:
Please make an appt with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15785**] and Dr. [**Last Name (STitle) 5717**] at
[**Hospital6 733**], [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] clinical
center, [**Telephone/Fax (1) 250**] when you get out of rehabilitation
.
Cardiology:
Name: [**Last Name (LF) 171**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: CARDIOVASCULAR DIVISION, [**Hospital Ward Name 23**] [**Location (un) 436**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 62**]
Appt: [**5-12**] at 1:20pm
{'Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Ventricular fibrillation,Acute and subacute necrosis of liver,Acute systolic heart failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Acidosis,Ventilator associated pneumonia,Other and unspecified coagulation defects,Coronary atherosclerosis of native coronary artery,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: s/p v. fib arrest

PRESENT ILLNESS: 39 y/oM with PMH of HTN, [**Hospital **] transferred from OSH s/p inferior-
lateral STEMI c/b vfib arrest in cardiogenic shock requiring
multiple pressors and intra-aortic balloon pump, on artic sun
protocol.
.
Per family and records, patient complained of intermittent chest
pain, cough, and URI symptoms x 3 days.  Yesterday after getting
home from work, he had worsening chest pressure and went to bed
early.  At 3:15am, wife reports hearing patient fall from bed.
He was found unresponsive with agonal respirations.  When EMS
arrived approx 30min later, patient was found to be in slow VT/
vfib arrest with "fixed and dilated pupils."  CPR was initiated
en route to OSH with shock x 1, epi x 2 and intubation.
.
At OSH, patient was hypotensive with SBP in 70s and EKG showing
STE in inferior-lateral leads.  Emergent cardiac catheterization
showed 100% mid-RCA occlusion, which was stented with [**Hospital **] x2.
He was given ASA 325 mg, a plavix load of 600 mg, 5000 unit
bolus of heparin, and integrillin gtt.  Intra-aortic balloon
pump was placed and started on dopamine and phenylephrine via
PIV for blood pressure support.  Labs prior to transfer were
significant for WBC of 10.8, trop < 0.01, CK 93 with ABG
7.14/40/407/13.  Patient was transferred to [**Hospital1 18**] for further
care with cooling initiated via 2L chilled NS during med flight.
 Med-flight also placed c-collar given report of trauma prior to
episode of unresponsiveness.
.
Upon transfer to CCU, patient intubated, hypothermic and sedate.
 Pupils minimally responsive with absent corneal reflex and
suppressed DTRs.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, + Hypertension

MEDICATION ON ADMISSION: lisinopril 10mg daily
metformin 1000 mg [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: GENERAL: intubated, sedate and hypothermic
HEENT: sclerae anicteric; dried blood around nares
NECK: unable to assess JVP given c-collar
CARDIAC: RRR S1 S2, intra-aortic balloon pump audible throughout
precordium
LUNGS: equal air entry bilaterally
ABDOMEN: soft/ ND/ NABS
EXTREMITIES: no c/c/e
NEURO: sedate, unresponsive.  pupils 3mm and minimally
responsive.  Corneal reflex absent.  Normal tone and bulk.  DTR
difficult to elicit. Toes downgoing b/l
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP dopperable
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+

FAMILY HISTORY: Family history uncertain but per wife, no history of early MI or
sudden cardiac death
father: CVA in late 60s

SOCIAL HISTORY: immigrant from [**Country 149**] approx 10 yrs ago.  Currently living with
wife and 2 children aged 10 and 6.
-Tobacco history: none
-ETOH: none, previously drank socially
-Illicit drugs: none 

### Response:
{'Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Ventricular fibrillation,Acute and subacute necrosis of liver,Acute systolic heart failure,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Acute respiratory failure,Acidosis,Ventilator associated pneumonia,Other and unspecified coagulation defects,Coronary atherosclerosis of native coronary artery,Anticoagulants causing adverse effects in therapeutic use'}
