CHIEF COMPLAINT: Chest pain and diaphoresis

PRESENT ILLNESS: This is a 75 year old male with history of nephrolothiasis s/p
percutaneous nephrostomy tube placement for urosepsis
complicated by atrial fibrillation with RVR, and nowpresented
with chest pain and atrial fibrillation with RVR.   He reports
that the morning of admission, aids at the rehab wererolling him
for a bath, when he had the acute onset of substernal chest
pressure, radiating down bilateral arms with associated
diaphoresis. He was given 2 SL NTG by EMS which improved pain
from [**10-22**] to [**2-21**]. In addition, he was noted by EMS to be
inatrial fibrillation with RVR. In the ED, patient was noted to
be in atrial fibrillation with RVR. He was admitted for further
evaluation and a cardiac catheterization was obtained and was
found to have coronary artery disease. He is now being referred
to cardiac surgery for revascularization.

MEDICAL HISTORY: - Coronary Artery Disease
- Diabetes
- Hypertension
- Chronic Systolic CHF (EF 35% on [**2121-5-8**])
- Atrial fibrillation on Coumadin
- Morbid Obesity
- Nephrolithiasis (since [**2069**])- recently obstructive causing
urosepsis, s/p right percutaneous nephrostomy tube placement
- s/p bilateral meniscal tears
- Positional vertigo
- Gout
- Right cataract surgery

MEDICATION ON ADMISSION: # aspirin 81 mg PO daily
# metoprolol succinate 200 mg PO daily
# lisinopril 2.5 mg PO daily
# warfarin 5 mg PO daily
# tamsulosin 0.4 mg PO qHS
# insulin glargine 100 unit/mL Solution 10 units SC qHS
# insulin aspart 100 unit/mL cartridge per sliding scale QACHS
# tramadol 50 mg PO BID prn pain
# miconazole nitrate 2 % Powder TOPICAL daily
# allopurinol 100 mg PO daily
# simethicone 80 mg PO q6-8h prn gas

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VS- 97.3 123/64 86 22 100% RA
GENERAL- obese male in NAD.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Oropharynx clear, no
lesions/exudate
NECK- Supple with JVP of 5 cm. Papular rash on neck
CARDIAC- Irregularly irregular, normal s1/s2, grade II/VI
systolic murmur best heard at LUSB, no radiation to carotids
LUNGS- CTA anteriorly, no crackles/wheezes
ABDOMEN- +BS, soft, NT, ND.
EXTREMITIES- WWP, no edema or cyanosis.
SKIN- Papular rash in folds of neck, dry skin on face. No stasis
dermatitis, ulcers, scars, or xanthomas.
Area surrounding percutaneous nephrostomy tube clean, no
erythema or exudate.
GU- foley in place draining clear/nonbloody urine.
Nephrostomy tube draining nonbloody urine with minimal sediment
No CVA tenderness bilaterally
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

FAMILY HISTORY: Father lost kidney due to stones
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: The patient lives with his wife [**Name (NI) **] in [**Location 110442**], MA,
however most recently he has been at [**Hospital 100**] Rehab, recently
transferred to [**Location (un) 169**]. He is a retired dry cleaning
machine manufacturerer
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Coronary atherosclerosis of native coronary artery,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Chronic systolic heart failure,Hydronephrosis,Bacteremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary obstruction, not elsewhere classified,Unspecified osteomyelitis, other specified sites,Intermediate coronary syndrome,Other postoperative infection,Atrial fibrillation,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,Calculus of kidney,Subendocardial infarction, subsequent episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Gout, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Body Mass Index 34.0-34.9, adult,Morbid obesity,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Crnry athrscl natve vssl,Pneumonia, organism NOS,Ac resp flr fol trma/srg,Chr systolic hrt failure,Hydronephrosis,Bacteremia,Klebsiella pneumoniae,React-indwell urin cath,Urinary obstruction NEC,Osteomyelit NOS-oth site,Intermed coronary synd,Other postop infection,Atrial fibrillation,Abn react-anastom/graft,Calculus of kidney,Subendo infarct, subseq,DMII wo cmp nt st uncntr,Hypertension NOS,Gout NOS,Old myocardial infarct,Long-term use anticoagul,BMI 34.0-34.9,adult,Morbid obesity,Abn react-urinary cath
Admission Date:  [**2121-6-7**]              Discharge Date:   [**2121-7-2**]

Date of Birth:  [**2045-7-26**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain and diaphoresis

Major Surgical or Invasive Procedure:
[**2121-6-16**] Urgent coronary artery bypass graft x4; left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal, obtuse marginal, and posterior left
ventricular branch.
.
[**2121-6-27**] Placement of Right Percutaneous Nephrostomy Tube


History of Present Illness:
This is a 75 year old male with history of nephrolothiasis s/p
percutaneous nephrostomy tube placement for urosepsis
complicated by atrial fibrillation with RVR, and nowpresented
with chest pain and atrial fibrillation with RVR.   He reports
that the morning of admission, aids at the rehab wererolling him
for a bath, when he had the acute onset of substernal chest
pressure, radiating down bilateral arms with associated
diaphoresis. He was given 2 SL NTG by EMS which improved pain
from [**10-22**] to [**2-21**]. In addition, he was noted by EMS to be
inatrial fibrillation with RVR. In the ED, patient was noted to
be in atrial fibrillation with RVR. He was admitted for further
evaluation and a cardiac catheterization was obtained and was
found to have coronary artery disease. He is now being referred
to cardiac surgery for revascularization.

Past Medical History:
- Coronary Artery Disease
- Diabetes
- Hypertension
- Chronic Systolic CHF (EF 35% on [**2121-5-8**])
- Atrial fibrillation on Coumadin
- Morbid Obesity
- Nephrolithiasis (since [**2069**])- recently obstructive causing
urosepsis, s/p right percutaneous nephrostomy tube placement
- s/p bilateral meniscal tears
- Positional vertigo
- Gout
- Right cataract surgery


Social History:
The patient lives with his wife [**Name (NI) **] in [**Location 110442**], MA,
however most recently he has been at [**Hospital 100**] Rehab, recently
transferred to [**Location (un) 169**]. He is a retired dry cleaning
machine manufacturerer
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies

Family History:
Father lost kidney due to stones
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
Admission Physical Exam:
VS- 97.3 123/64 86 22 100% RA
GENERAL- obese male in NAD.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Oropharynx clear, no
lesions/exudate
NECK- Supple with JVP of 5 cm. Papular rash on neck
CARDIAC- Irregularly irregular, normal s1/s2, grade II/VI
systolic murmur best heard at LUSB, no radiation to carotids
LUNGS- CTA anteriorly, no crackles/wheezes
ABDOMEN- +BS, soft, NT, ND.
EXTREMITIES- WWP, no edema or cyanosis.
SKIN- Papular rash in folds of neck, dry skin on face. No stasis
dermatitis, ulcers, scars, or xanthomas.
Area surrounding percutaneous nephrostomy tube clean, no
erythema or exudate.
GU- foley in place draining clear/nonbloody urine.
Nephrostomy tube draining nonbloody urine with minimal sediment
No CVA tenderness bilaterally
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+


Pertinent Results:
Coronary Catheterization [**2121-6-11**]:
1.  Selective coronary angiography of this right dominant system

demonstrated severe left main and three vessel coronary artery
disease.
The LMCA had a distail 70% stenosis.  The LAD had serial proxmal
and mid
vessel lesions up to 80% in narrowing.  The distal vessel was
small with
diffuse disease.  The LCx had a subtotal occlusion proximally.
The RCA
was a large ectactic vessel.  There was a proximal 70% narrowing
with
diffuse moderate disease and severe disease of the small distal
branch
vessels.  All vessels were heavily calcified.
2.  Limited resting hemodynamics revaled elevated left
ventricular
filling pressure, with an LVEDP of 20 mmHg.  There was no
transvavular
gradient to suggest aortic stenosis.  There was normal systemic
blood
pressure, with a central aortic pressure of 124/73mmHg.
.
Carotid Series [**2121-6-13**]:
IMPRESSION:  Less than 40% stenosis in the bilateral internal
carotid
arteries.  Mild heterogeneous plaques are seen in the bilateral
proximal
internal carotid arteries.
.
Intra-op TEE [**2121-6-16**]:
PRE-BYPASS: The left atrium is moderately dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. There is moderate to severe regional left
ventricular systolic dysfunction with mid-apical anterior,
anteroseptal sever hypokinesis. Overall left ventricular
systolic function is moderately depressed (LVEF= 30-35 %). The
right ventricular cavity is mildly dilated with borderline
normal free wall function. There are simple atheroma in the
ascending aorta. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**1-13**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly directed jet of
There is no pericardial effusion.
POST CPB: 1. Improverd global and focal LV systolic function
with persistent WMA's but of lesser severity. EF =35-40% 2. MR
is now mild. 3. No other change in valve structure and function

.
Chest CT Scan [**2121-7-1**]:
1.  Postoperative changes from coronary artery bypass graft with
sternotomy noted and mild stranding of the superficial and
mediastinal soft tissues, likely postoperative in nature without
focal fluid collection.  No evidence of osteomyelitis or
breakdown of the sternal wound. 2.  Left greater than right
moderate pleural effusions with accompanying atelectasis and
right lower lobar consolidative opacity which may reflect
aspiration or developing pneumonia. 3.  Moderate cardiomegaly
with coronary vascular disease, aortic valvular calcifications
and enlarged pulmonary artery suggesting pulmonary hypertension.

.
LABS
[**2121-7-2**] WBC-8.3 RBC-3.19* Hgb-9.0* Hct-28.9*  RDW-15.3 Plt
Ct-433
[**2121-7-1**] WBC-7.7 RBC-2.99* Hgb-8.7* Hct-27.7* RDW-15.4 Plt
Ct-413
[**2121-6-30**] WBC-7.5 RBC-3.09* Hgb-9.0* Hct-28.8* RDW-15.4 Plt
Ct-386
[**2121-6-29**] WBC-9.1 RBC-2.92* Hgb-8.6* Hct-27.2*  RDW-15.7* Plt
Ct-385
[**2121-6-28**] WBC-11.1* RBC-3.05* Hgb-8.7* Hct-28.5*  RDW-15.6* Plt
Ct-332
[**2121-7-2**] PT-17.9* INR(PT)-1.7*
[**2121-7-1**] PT-24.8* INR(PT)-2.4*
[**2121-6-30**] PT-26.2* INR(PT)-2.5*
[**2121-6-29**] PT-24.7* INR(PT)-2.4*
[**2121-6-28**] PT-29.5* INR(PT)-2.8*
[**2121-7-2**] Glucose-113* UreaN-24* Creat-1.0 Na-132* K-4.9 Cl-97
[**2121-7-1**] Glucose-107* UreaN-25* Creat-1.0 Na-134 K-4.5 Cl-97
HCO3-32
06/18/12Glucose-88 UreaN-24* Creat-1.0 Na-133 K-4.4 Cl-97
HCO3-32 AnGap-8
[**2121-6-29**] Glucose-98 UreaN-27* Creat-1.0 Na-133 K-4.7 Cl-97
HCO3-31 AnGap-10
[**2121-6-28**] Glucose-106* UreaN-30* Creat-1.1 Na-137 K-4.5 Cl-101
HCO3-31
[**2121-6-26**] Glucose-110* UreaN-35* Creat-1.1 Na-135 K-4.2 Cl-100
HCO3-30
[**2121-6-25**] Glucose-108* UreaN-42* Creat-1.3* Na-136 K-4.2 Cl-100
HCO3-27
[**2121-6-22**] Glucose-107* UreaN-53* Creat-1.8* Na-140 K-4.2 Cl-103
HCO3-26
[**2121-7-2**] Mg-2.0

Brief Hospital Course:
MEDICAL COURSE:
75 yo M with h/o HTN, DMII, nephrolithiasis s/p right
percutaneous nephrostomy tube for obstructing calculus causing
urosepsis, afib on coumadin, now presenting with chest pressure
and diaphoresis with RVR with pseudomonal UTI.

PREOPERATIVE COURSE:
# Demand Ischemia/3-Vessel CAD s/p CABG: Patient was admitted
with chest pain which occurred in the setting of movement, and
on EMS arrival, was found to be in RVR.  He had a mild troponin
leak to a peak level of 0.07 without elevation of CKMB and
without EKG changes.  His chest pain was assessed as demand
ischemia caused by his Afib with rapid ventricular rate.
Patient had recent NSTEMI during prior admission and underwent
C. cath here which showed severe 3 vessel disease including a
70% left main lesion. He was medically managed with aspirin
325mg, atorvastatin 40mg daily, rate control with metoprolol
which was uptitrated to 100mg PO QID, and coumadin for his afib
in place of heparin. He was referred to cardiac surgery for
CABG, underwent unremarkable pre-CABG work-up including carotid
U/S and his coumadin was held and replaced with a heparin drip
as a bridge prior to surgery.
.
# Atrial fibrillation with RVR: During last admission, patient
had rapid rates with small amounts of activity, and his RVR on
this occasion occurred in the setting of lots of movement.  He
had no evidence of pneumonia on CXR and d-dimer was negative, so
low suspicion for pulmonary embolism. He was monitored on
telemetry and his metoprolol was uptitrated to 100mg PO QID on
which he achieved good rate control. Patient had no ongoing
episodes of RVR during admission.

# Pseudomonas UTI: Patient had recent urosepsis secondary to
obstructive calculus in right kidney and patient now has right
percutaneous nephrostomy tube and foley catheter which puts him
at risk for UTI and pyelonephritis. He was initially started
broadly on vancomycin/ceftriaxone which was changed to cefepime
once urine culture grew pseudomonas. He was ultimately narrowed
to oral cipro once sensitivities were available and was treated
for a total 10-day course for complicated UTI with clearance of
his urine cultures.

SURGICAL COURSE:
On [**2121-6-16**], underwent four vessel coronary artery bypass grafting
by Dr. [**First Name (STitle) **].  Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.

POSTOPERATIVE COURSE:

# Urosepsis/Sternal Wound Infection/Pneumonia: Experienced
fevers, pyuria and sternal drainage. Blood, urine and wound
cultures grew out Klebsiella pneumoniae. Followed by ID service
and intravenous antibiotics were titrated accordingly. At
discharge, antibiotics were Ertapenem and Vancomycin. Ertapenem
will be for approximately for 6 weeks. Just prior to discharge,
Vancomycin was added for 14 days for postoperative pneumonia
found on chest CT scan. PICC line will placed at [**Hospital 100**] rehab
and he will continue to followup with ID as outpatient. While at
rehab, patient will require weekly CBC with diff, BMP, LFT's,
ESR, CRP and BNP. Vancomycin will be titrated for a goal trough
between 15 - 20. During hospital stay, bedside debridement of
sternal wound was performed. At discharge, VAC dressing was in
place.

# Obstructive Nephrolithiasis: Underwent placement of a right
nephrostomy tube and will followup with Dr. [**First Name (STitle) **] [**Name (STitle) **] as
outpatient. At time of dicharge, Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] on vacation but
will contact patient at [**Hospital 100**] rehab upon his return. He is
currently scheduled for ureteroscopy with laser lithotripsy on
[**2121-8-12**].

# Atrial Fibrillation: Remained in a rate controlled atrial
fibrillation. Maintained on Amiodarone and Diltiazem. Warfarin
was dosed for a goal INR between 2.0 - 3.0.

# Disposition: Discharged to [**Hospital 100**] Rehab on postoperative day
16


Medications on Admission:
# aspirin 81 mg PO daily
# metoprolol succinate 200 mg PO daily
# lisinopril 2.5 mg PO daily
# warfarin 5 mg PO daily
# tamsulosin 0.4 mg PO qHS
# insulin glargine 100 unit/mL Solution 10 units SC qHS
# insulin aspart 100 unit/mL cartridge per sliding scale QACHS
# tramadol 50 mg PO BID prn pain
# miconazole nitrate 2 % Powder TOPICAL daily
# allopurinol 100 mg PO daily
# simethicone 80 mg PO q6-8h prn gas

Discharge Medications:
1. furosemide 10 mg/mL Solution Sig: Four (4) ml Injection [**Hospital1 **]
(2 times a day): 40mg IV twice daily.
2. vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous Q
12H (Every 12 Hours) for 14 days: started [**2121-7-2**].
3. ertapenem 1 gram Recon Soln Sig: One (1)  Intravenous Q24
hours () for 6 weeks: started [**2121-7-2**].
4. diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day): hold for SBP<95 or HR<85 .
5. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours).
6. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical HS
(at bedtime): apply to affected area.
11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.

14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. warfarin 1 mg Tablet Sig: 0.5 Tablet PO at bedtime: Take as
directed by MD. Daily dose may vary according to PT/INR. Goal
INR between 2.0 - 3.0.
16. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**6-20**]
hours as needed for pain, fever.
18. insulin regular human 100 unit/mL Solution Sig: per sliding
scale  Injection ASDIR (AS DIRECTED).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
-Coronary Artery Disease, s/p CABG
-Postop Sternal Wound Infection, on VAC dressing
-Diabetes Mellitus
-Morbid Obesity
-Hypertension
-Systolic CHF (EF 35% on [**2121-5-8**])
-Atrial fibrillation on Coumadin
-Nephrolithiasis (since [**2069**])- recently obstructive causing
Klebsiella urosepsis, s/p right percutaneous nephrostomy tube
placement
-Postop Pneumonia


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - VAC dressing in place


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **]  [**Telephone/Fax (1) 170**] [**2121-7-22**] at 1:00p
Cardiologist Dr. [**Last Name (STitle) 696**] [**Telephone/Fax (1) 62**] Date/Time:[**2121-8-7**] 10:00
Infectious Disease: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2121-7-18**] @ [**Hospital Unit Name **]
Basement
Urology: Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 4376**] - Dr. [**Last Name (STitle) **] [**First Name (STitle) **] contact
patient at [**Hospital 100**] Rehab with followup instructions

Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 31293**] in [**4-17**] 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**

Labs: PT/INR
Coumadin for afib
Goal INR [**2-14**]
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 4467**]
Results to phone fax ([**Telephone/Fax (1) 110443**]
.
***Also needs weekly CBC with diff, chem 7, LFT's, BNP, ESR and
CRP. Results should be faxed to [**Hospital1 18**] ID office at
[**Telephone/Fax (1) 1419**].*** Also check Vanco trough after 4th dose -
Vancomycin should be titrated for goal Vanco trough between 15 -
20.****
.
Please change VAC dressing every three days.


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

Completed by:[**2121-7-2**]
{"Coronary atherosclerosis of native coronary artery,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Chronic systolic heart failure,Hydronephrosis,Bacteremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary obstruction, not elsewhere classified,Unspecified osteomyelitis, other specified sites,Intermediate coronary syndrome,Other postoperative infection,Atrial fibrillation,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,Calculus of kidney,Subendocardial infarction, subsequent episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Gout, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Body Mass Index 34.0-34.9, adult,Morbid obesity,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure"}


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 and diaphoresis

PRESENT ILLNESS: This is a 75 year old male with history of nephrolothiasis s/p
percutaneous nephrostomy tube placement for urosepsis
complicated by atrial fibrillation with RVR, and nowpresented
with chest pain and atrial fibrillation with RVR.   He reports
that the morning of admission, aids at the rehab wererolling him
for a bath, when he had the acute onset of substernal chest
pressure, radiating down bilateral arms with associated
diaphoresis. He was given 2 SL NTG by EMS which improved pain
from [**10-22**] to [**2-21**]. In addition, he was noted by EMS to be
inatrial fibrillation with RVR. In the ED, patient was noted to
be in atrial fibrillation with RVR. He was admitted for further
evaluation and a cardiac catheterization was obtained and was
found to have coronary artery disease. He is now being referred
to cardiac surgery for revascularization.

MEDICAL HISTORY: - Coronary Artery Disease
- Diabetes
- Hypertension
- Chronic Systolic CHF (EF 35% on [**2121-5-8**])
- Atrial fibrillation on Coumadin
- Morbid Obesity
- Nephrolithiasis (since [**2069**])- recently obstructive causing
urosepsis, s/p right percutaneous nephrostomy tube placement
- s/p bilateral meniscal tears
- Positional vertigo
- Gout
- Right cataract surgery

MEDICATION ON ADMISSION: # aspirin 81 mg PO daily
# metoprolol succinate 200 mg PO daily
# lisinopril 2.5 mg PO daily
# warfarin 5 mg PO daily
# tamsulosin 0.4 mg PO qHS
# insulin glargine 100 unit/mL Solution 10 units SC qHS
# insulin aspart 100 unit/mL cartridge per sliding scale QACHS
# tramadol 50 mg PO BID prn pain
# miconazole nitrate 2 % Powder TOPICAL daily
# allopurinol 100 mg PO daily
# simethicone 80 mg PO q6-8h prn gas

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
VS- 97.3 123/64 86 22 100% RA
GENERAL- obese male in NAD.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Oropharynx clear, no
lesions/exudate
NECK- Supple with JVP of 5 cm. Papular rash on neck
CARDIAC- Irregularly irregular, normal s1/s2, grade II/VI
systolic murmur best heard at LUSB, no radiation to carotids
LUNGS- CTA anteriorly, no crackles/wheezes
ABDOMEN- +BS, soft, NT, ND.
EXTREMITIES- WWP, no edema or cyanosis.
SKIN- Papular rash in folds of neck, dry skin on face. No stasis
dermatitis, ulcers, scars, or xanthomas.
Area surrounding percutaneous nephrostomy tube clean, no
erythema or exudate.
GU- foley in place draining clear/nonbloody urine.
Nephrostomy tube draining nonbloody urine with minimal sediment
No CVA tenderness bilaterally
PULSES-
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

FAMILY HISTORY: Father lost kidney due to stones
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: The patient lives with his wife [**Name (NI) **] in [**Location 110442**], MA,
however most recently he has been at [**Hospital 100**] Rehab, recently
transferred to [**Location (un) 169**]. He is a retired dry cleaning
machine manufacturerer
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies 

### Response:
{"Coronary atherosclerosis of native coronary artery,Pneumonia, organism unspecified,Acute respiratory failure following trauma and surgery,Chronic systolic heart failure,Hydronephrosis,Bacteremia,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Infection and inflammatory reaction due to indwelling urinary catheter,Urinary obstruction, not elsewhere classified,Unspecified osteomyelitis, other specified sites,Intermediate coronary syndrome,Other postoperative infection,Atrial fibrillation,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,Calculus of kidney,Subendocardial infarction, subsequent episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Gout, unspecified,Old myocardial infarction,Long-term (current) use of anticoagulants,Body Mass Index 34.0-34.9, adult,Morbid obesity,Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure"}
