CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: Patient is a 51 year-old male with a past medical history of
NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to
the LAD, depression presenting with acute onset chest pain
beginning at around 8 AM as his car was getting towed and he was
running.  He describes the pain as pressure-like beginning
substernally, radiating to the back and right side of the chest,
initially an [**6-26**], associated with SOB and some nausea.  Of
note, he had not taken his aspirin this morning.  The pain went
down slightly after this event, and he went to his psychiatry
appointment at [**Hospital1 **].  While at the appointment, the pressure was
present at roughly [**5-26**].  The appointment ended, and he was
walking to the car when the pressure, SOB, and nausea became so
severe that he could not walk.  He thus presented to the ED.
.
On arrival to the ED, initial vitals were 96.3 73 142/91 16
100%.  Initial ECG showed NSR, no ST changes compared with
prior.  Patient received aspirin and NG, and the pain came down
to [**2-24**], became more comfortable.  A half an hour, patient was
sleeping, but upon awakening reported worsening 7/10 chest pain,
not relieved with 3 x NG. A repeat ECG showed NSR, new RBBB,
right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S
wave in V4/V5, 1-2 mm STE in v3/v4.  Code STEMI called, patient
started on a heparin gtt, given Plavix 600 mg, started on an
integrillin gtt, and taken to the cath lab.  In the cath lab,
cath showed aneurysm formation within the DES to the LAD, with
stents widely patent except for a 70-80% stenosis in the mid
LAD. This lesion was ballooned and a BMS (Integrity) placed.  He
arrived to the CCU pain free and comfortable.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.  He is normally very
active, walking 30-40 min several days a week, walking flights
of stairs without issue.
.
Of note, after his NSTEMI, he was started on metoprolol and
lisinopril.  The lisinopril was discontinued after symptoms of
lightheadedness, and metoprolol discontinued in [**2162**] after he
had fatigue and lightheadedness.  He has had intolerance to
lipitor, zetia in the past secondary to vague symptoms
(abdominal pain, fatigue).

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG:  None
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD, PTCA to Ramus
in [**2161**]
- PACING/ICD:  None
3. OTHER PAST MEDICAL HISTORY:
.
1. Status post penile surgery.
2. Perioral vitiligo.
3. Erectile dysfunction.
4. CAD: Acute MI [**9-16**], s/p stenting to LAD and PTCA to ramus
5. Depression

MEDICATION ON ADMISSION: - Citalopram 20 mg
- Ibuprofen 400 TID PRN
- Niacin [Niaspan Extended-Release] 500 mg PO BID
- NG .4 SL PRN
- Crestor 5 mg once a day
- Tacrolimus [Protopic] 0.1 % Ointment apply to affected areas
[**Hospital1 **]
- Aspirin 81 mg

ALLERGIES: Simvastatin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
.
Tm: 36.6 ??????C (97.9 ??????F), Tc: 36.6 ??????C (97.9 ??????F) HR: 77 (73 - 102)
bpm BP: 125/77(90) {112/69(82) - 131/80(91)} mmHg RR: 25 (19 -
25) insp/min
SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal, No(t) Widely split ),
No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
.
DISCHARGE PHYSICAL EXAM:
.
Tm: 36.8 ??????C (98.2 ??????F), Tc: 36.8 ??????C (98.2 ??????F)HR: 78 (73 - 102)
bpm
BP: 102/61(65) {94/51(58) - 131/113(117)} mmHgRR: 19 (19 - 25)
insp/min
SpO2: 97%
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: RRR, nl S1/S2, no m/r/g S4, no elevated JVP
Peripheral Vascular: 2+ peripheral pulses in UE??????s and LE??????s
Respiratory / Chest: CTAB, no rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No significant LE edema
Skin:  Not assessed
Neurologic: CN??????s III-XII intact, [**3-21**] motor in BUE and BLE??????s, no
gross sensory deficits

FAMILY HISTORY: No history of premature cardiac disease in family. Otherwise
noncontibutory.

SOCIAL HISTORY: Lives at home with wife. [**Name (NI) **] 4 children. Manages a [**Doctor Last Name 9381**] gas
station. He denies tobacco, ETOH, or drug use.
Other complications due to other cardiac device, implant, and graft,Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Adjustment disorder with depressed mood,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Right bundle branch block
Comp-oth cardiac device,AMI anterior wall, init,Crnry athrscl natve vssl,Old myocardial infarct,Adjustmnt dis w depressn,Status-post ptca,Hyperlipidemia NEC/NOS,Abn react-artif implant,Rt bundle branch block
Admission Date:  [**2165-9-9**]              Discharge Date:   [**2165-9-11**]

Date of Birth:  [**2113-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
Simvastatin

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
cardiac catheterization with bare metal stent to the mid left
anterior descending artery


History of Present Illness:
Patient is a 51 year-old male with a past medical history of
NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to
the LAD, depression presenting with acute onset chest pain
beginning at around 8 AM as his car was getting towed and he was
running.  He describes the pain as pressure-like beginning
substernally, radiating to the back and right side of the chest,
initially an [**6-26**], associated with SOB and some nausea.  Of
note, he had not taken his aspirin this morning.  The pain went
down slightly after this event, and he went to his psychiatry
appointment at [**Hospital1 **].  While at the appointment, the pressure was
present at roughly [**5-26**].  The appointment ended, and he was
walking to the car when the pressure, SOB, and nausea became so
severe that he could not walk.  He thus presented to the ED.
.
On arrival to the ED, initial vitals were 96.3 73 142/91 16
100%.  Initial ECG showed NSR, no ST changes compared with
prior.  Patient received aspirin and NG, and the pain came down
to [**2-24**], became more comfortable.  A half an hour, patient was
sleeping, but upon awakening reported worsening 7/10 chest pain,
not relieved with 3 x NG. A repeat ECG showed NSR, new RBBB,
right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S
wave in V4/V5, 1-2 mm STE in v3/v4.  Code STEMI called, patient
started on a heparin gtt, given Plavix 600 mg, started on an
integrillin gtt, and taken to the cath lab.  In the cath lab,
cath showed aneurysm formation within the DES to the LAD, with
stents widely patent except for a 70-80% stenosis in the mid
LAD. This lesion was ballooned and a BMS (Integrity) placed.  He
arrived to the CCU pain free and comfortable.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.  He is normally very
active, walking 30-40 min several days a week, walking flights
of stairs without issue.
.
Of note, after his NSTEMI, he was started on metoprolol and
lisinopril.  The lisinopril was discontinued after symptoms of
lightheadedness, and metoprolol discontinued in [**2162**] after he
had fatigue and lightheadedness.  He has had intolerance to
lipitor, zetia in the past secondary to vague symptoms
(abdominal pain, fatigue).


Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG:  None
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD, PTCA to Ramus
in [**2161**]
- PACING/ICD:  None
3. OTHER PAST MEDICAL HISTORY:
.
1. Status post penile surgery.
2. Perioral vitiligo.
3. Erectile dysfunction.
4. CAD: Acute MI [**9-16**], s/p stenting to LAD and PTCA to ramus
5. Depression

Social History:
Lives at home with wife. [**Name (NI) **] 4 children. Manages a [**Doctor Last Name 9381**] gas
station. He denies tobacco, ETOH, or drug use.


Family History:
No history of premature cardiac disease in family. Otherwise
noncontibutory.

Physical Exam:
ADMISSION PHYSICAL EXAM:
.
Tm: 36.6 ??????C (97.9 ??????F), Tc: 36.6 ??????C (97.9 ??????F) HR: 77 (73 - 102)
bpm BP: 125/77(90) {112/69(82) - 131/80(91)} mmHg RR: 25 (19 -
25) insp/min
SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal, No(t) Widely split ),
No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
.
DISCHARGE PHYSICAL EXAM:
.
Tm: 36.8 ??????C (98.2 ??????F), Tc: 36.8 ??????C (98.2 ??????F)HR: 78 (73 - 102)
bpm
BP: 102/61(65) {94/51(58) - 131/113(117)} mmHgRR: 19 (19 - 25)
insp/min
SpO2: 97%
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: RRR, nl S1/S2, no m/r/g S4, no elevated JVP
Peripheral Vascular: 2+ peripheral pulses in UE??????s and LE??????s
Respiratory / Chest: CTAB, no rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No significant LE edema
Skin:  Not assessed
Neurologic: CN??????s III-XII intact, [**3-21**] motor in BUE and BLE??????s, no
gross sensory deficits

Pertinent Results:
ADMISSION LABS:
.
[**2165-9-9**] 10:20AM BLOOD WBC-10.2 RBC-5.15 Hgb-16.1 Hct-45.2
MCV-88 MCH-31.2 MCHC-35.5* RDW-12.5 Plt Ct-278
[**2165-9-9**] 10:20AM BLOOD Neuts-73.5* Lymphs-18.7 Monos-5.3 Eos-1.9
Baso-0.5
[**2165-9-9**] 10:20AM BLOOD Plt Ct-278
[**2165-9-9**] 06:15PM BLOOD Plt Ct-308
[**2165-9-9**] 10:20AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-138
K-3.6 Cl-102 HCO3-25 AnGap-15
[**2165-9-9**] 10:20AM BLOOD Lipase-61*
[**2165-9-9**] 10:20AM BLOOD CK-MB-4
[**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01
[**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64*
[**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66*
.
PERTINENT LABS:
.
[**2165-9-10**] 04:25AM BLOOD CK(CPK)-423*
[**2165-9-9**] 10:20AM BLOOD Lipase-61*
[**2165-9-9**] 10:20AM BLOOD CK-MB-4
[**2165-9-9**] 10:20AM BLOOD cTropnT-<0.01
[**2165-9-9**] 06:15PM BLOOD CK-MB-48* cTropnT-2.64*
[**2165-9-10**] 04:25AM BLOOD CK-MB-34* MB Indx-8.0* cTropnT-1.66*
[**2165-9-10**] 04:25AM BLOOD %HbA1c-5.4 eAG-108
[**2165-9-10**] 04:25AM BLOOD Triglyc-150* HDL-38 CHOL/HD-3.6
LDLcalc-67 LDLmeas-79
.
DISCHARGE LABS:
.
[**2165-9-11**] 06:00AM BLOOD WBC-9.1 RBC-4.98 Hgb-15.2 Hct-44.5 MCV-90
MCH-30.5 MCHC-34.1 RDW-12.4 Plt Ct-298
[**2165-9-11**] 06:00AM BLOOD Plt Ct-298
[**2165-9-11**] 06:00AM BLOOD PT-11.8 PTT-27.9 INR(PT)-1.0
[**2165-9-11**] 06:00AM BLOOD Glucose-105* UreaN-11 Creat-0.8 Na-136
K-4.1 Cl-103 HCO3-25 AnGap-12
[**2165-9-11**] 06:00AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.1
.
MICRO/PATH:
.
MRSA Screening: PENDING
.
IMAGING/STUDIES:
.
Cardiac Cath [**2165-9-9**]:
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of ISRS proximal LAD with BMS.
3. Successful RRA TR band.
.
ECG [**2165-9-6**]:
Sinus rhythm. Resolution of anterior ST segment elevation.
Morphology of this tracing is identical to that seen on tracing
#1. Right bundle-branch block is no longer seen.
.
TTE [**2165-9-10**]: LVEF 60%
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 normal
(LVEF 60%). However, the midventricular segment of the anterior
and lateral walls appears hypokinetic. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets are myxomatous. There is
mild bileaflet mitral valve prolapse. Trivial mitral
regurgitation is seen. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2162-9-17**], the findings are similar.

Brief Hospital Course:
51 year-old male with a past medical history of NSTEMI in [**2161**]
s/p POBA to the culprit occluded ramus and DES to the LAD,
hyperlipidemia, depression presenting with acute onset chest
pain this morning, symptoms indicative of unstable angina, new
RBBB, J point elevations on ECG, now s/p BMS to mid LAD lesion.
.
ACTIVE DIAGNOES:
.
# NSTEMI S/P BMS to LAD:  Pt presented same day with acute
severe anginal chest pain, ECG showed NSR, new RBBB, right asix
deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S wave in
V4/V5, 1-2 mm STE in v3/v4.  Code STEMI was called, patient
started on ASA 325mg, heparin drip, loading dose of Plavix,
started on an integrillin drip, and taken to the cath lab.  Cath
showed aneurysm formation within the DES to the LAD, with stents
widely patent except for a 70-80% stenosis in the mid LAD. This
lesion was ballooned and a BMS (Integrity) placed to mid LAD.
His pain rapidly improved and follow-up EKG's showed resolution
of his RBBB and normal sinus rhythm. TTE showed LVEF of 60% but
the midventricular segment of the anterior and lateral walls
appear hypokinetic. He was discharged on 325 aspirin daily, 75mg
plavix, 25 metoprolol tartrate [**Hospital1 **], and re-started on his prior
home crestor with follow-up arranged with his outpt PCP and
cardiologist. He was instructed to to stop his niacin and
ibuprofen.
.
CHRONIC DIAGNOSES:
.
# HLD: Stable. Total Chol 135, Trigs 150, HDL 38, LDL 79. He was
re-started on his home crestor 5mg PO 3 days weekly. He did not
previously tolerate atorvaststain (developed weakness and
abdominal pain) and has had trouble with other statins
previously.
.
# Depression: Stable. Continued on his home citalopram.
.
TRANSITIONAL ISSUES:
.
1)Pt has new BMS to mid LAD, on plavix and ASA 325mg. Follow-up
set up with his home cardiologist who will manage his cardiac
meds.
2)Pt has history of poor medication compliance especially with
statin drugs. His LDL was 79 here, would likely benefit from
aggressive lowering to <70. He is on the largest dose of crestor
that we think he will presently tolerate. Would attempt to
uptitrate as an outpatient.

Medications on Admission:
- Citalopram 20 mg
- Ibuprofen 400 TID PRN
- Niacin [Niaspan Extended-Release] 500 mg PO BID
- NG .4 SL PRN
- Crestor 5 mg once a day
- Tacrolimus [Protopic] 0.1 % Ointment apply to affected areas
[**Hospital1 **]
- Aspirin 81 mg

Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
3. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO three times a
week.
Disp:*30 Tablet(s)* Refills:*2*

Discharge Disposition:
Home

Discharge Diagnosis:
Non ST Elevation myocardial infarction
Dyslipidemia
Depression


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


Discharge Instructions:
Dear Mr. [**Known lastname 93439**],

It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**].  You were admitted to the hospital because you were
having a heart attack.  You had a catheterization of your heart,
and you were found to have a blockage in your left anterior
descending artery that was cleared and a bare metal stent was
placed. You will need to take plavix and aspirin every day for
at least one month and likely for much longer. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 11014**]s or stop taking Plavix unless Dr. [**Last Name (STitle) **] tells you that it
is OK. You should continue to take your other medicines as noted
below. Please follow physical therapy instructions for activity
for the next few weeks.
.
We made the following changes to your medicines:
1. STOP taking Ibuprofen, take tylenol as needed for pain
instead
2. Increase aspirin to 325 mg daily
3. START taking clopidogrel (Plavix) to keep the stent from
clotting off and causing another heart attack. Only Dr. [**Last Name (STitle) **]
will tell you when it is OK to stop this medicine
4. START taking metoprolol twice daily to help your heart
recover from the heart attack.
5. Continue Crestor at 5 mg daily to lower your cholesterol.
Please try to take every day if you can.
6. STOP taking niacin per Dr. [**Last Name (STitle) **]

Followup Instructions:
Department: PSYCHIATRY
When: MONDAY [**2165-10-21**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1387**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 551**]
Campus: EAST     Best Parking: Main Garage

Department: [**Hospital3 249**]
When: FRIDAY [**2165-9-13**] at 3:00 PM
With: [**Doctor First Name 26**] KOPLOW, LICSW [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2165-11-7**] at 9:10 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: MONDAY [**2165-9-16**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2165-9-25**] at 11:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2165-9-11**]
{'Other complications due to other cardiac device, implant, and graft,Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Adjustment disorder with depressed mood,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Right bundle branch block'}


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: Patient is a 51 year-old male with a past medical history of
NSTEMI in [**2161**] s/p POBA to the culprit occluded ramus and DES to
the LAD, depression presenting with acute onset chest pain
beginning at around 8 AM as his car was getting towed and he was
running.  He describes the pain as pressure-like beginning
substernally, radiating to the back and right side of the chest,
initially an [**6-26**], associated with SOB and some nausea.  Of
note, he had not taken his aspirin this morning.  The pain went
down slightly after this event, and he went to his psychiatry
appointment at [**Hospital1 **].  While at the appointment, the pressure was
present at roughly [**5-26**].  The appointment ended, and he was
walking to the car when the pressure, SOB, and nausea became so
severe that he could not walk.  He thus presented to the ED.
.
On arrival to the ED, initial vitals were 96.3 73 142/91 16
100%.  Initial ECG showed NSR, no ST changes compared with
prior.  Patient received aspirin and NG, and the pain came down
to [**2-24**], became more comfortable.  A half an hour, patient was
sleeping, but upon awakening reported worsening 7/10 chest pain,
not relieved with 3 x NG. A repeat ECG showed NSR, new RBBB,
right asix deviation, [**Street Address(2) 1766**] depressions V2/V3 with a deep S
wave in V4/V5, 1-2 mm STE in v3/v4.  Code STEMI called, patient
started on a heparin gtt, given Plavix 600 mg, started on an
integrillin gtt, and taken to the cath lab.  In the cath lab,
cath showed aneurysm formation within the DES to the LAD, with
stents widely patent except for a 70-80% stenosis in the mid
LAD. This lesion was ballooned and a BMS (Integrity) placed.  He
arrived to the CCU pain free and comfortable.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.  He is normally very
active, walking 30-40 min several days a week, walking flights
of stairs without issue.
.
Of note, after his NSTEMI, he was started on metoprolol and
lisinopril.  The lisinopril was discontinued after symptoms of
lightheadedness, and metoprolol discontinued in [**2162**] after he
had fatigue and lightheadedness.  He has had intolerance to
lipitor, zetia in the past secondary to vague symptoms
(abdominal pain, fatigue).

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG:  None
- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD, PTCA to Ramus
in [**2161**]
- PACING/ICD:  None
3. OTHER PAST MEDICAL HISTORY:
.
1. Status post penile surgery.
2. Perioral vitiligo.
3. Erectile dysfunction.
4. CAD: Acute MI [**9-16**], s/p stenting to LAD and PTCA to ramus
5. Depression

MEDICATION ON ADMISSION: - Citalopram 20 mg
- Ibuprofen 400 TID PRN
- Niacin [Niaspan Extended-Release] 500 mg PO BID
- NG .4 SL PRN
- Crestor 5 mg once a day
- Tacrolimus [Protopic] 0.1 % Ointment apply to affected areas
[**Hospital1 **]
- Aspirin 81 mg

ALLERGIES: Simvastatin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
.
Tm: 36.6 ??????C (97.9 ??????F), Tc: 36.6 ??????C (97.9 ??????F) HR: 77 (73 - 102)
bpm BP: 125/77(90) {112/69(82) - 131/80(91)} mmHg RR: 25 (19 -
25) insp/min
SpO2: 99% Heart rhythm: SR (Sinus Rhythm) Height: 65 Inch
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal, No(t) Widely split ),
No(t) S4
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse:
Present), (Right DP pulse: Present), (Left DP pulse: Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin:  Not assessed
.
DISCHARGE PHYSICAL EXAM:
.
Tm: 36.8 ??????C (98.2 ??????F), Tc: 36.8 ??????C (98.2 ??????F)HR: 78 (73 - 102)
bpm
BP: 102/61(65) {94/51(58) - 131/113(117)} mmHgRR: 19 (19 - 25)
insp/min
SpO2: 97%
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Cardiovascular: RRR, nl S1/S2, no m/r/g S4, no elevated JVP
Peripheral Vascular: 2+ peripheral pulses in UE??????s and LE??????s
Respiratory / Chest: CTAB, no rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: No significant LE edema
Skin:  Not assessed
Neurologic: CN??????s III-XII intact, [**3-21**] motor in BUE and BLE??????s, no
gross sensory deficits

FAMILY HISTORY: No history of premature cardiac disease in family. Otherwise
noncontibutory.

SOCIAL HISTORY: Lives at home with wife. [**Name (NI) **] 4 children. Manages a [**Doctor Last Name 9381**] gas
station. He denies tobacco, ETOH, or drug use. 

### Response:
{'Other complications due to other cardiac device, implant, and graft,Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Adjustment disorder with depressed mood,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Right bundle branch block'}
