CHIEF COMPLAINT: Tremors, chest pain

PRESENT ILLNESS: 77 yo M w/ h/o DM type 2, HTN, dyslidemia, NASH cirrhosis/HCC
s/p liver [**First Name3 (LF) **] who presents w/ tremors and chest pain. Pt
reports was in usual state of health until around 11:30pm night
prior to presentation. At that time noted "rope-like" pain
around his chest while watching TV on the couch. Pain lessened
and he was able to go upstairs and go to sleep. He awoke 1 hour
later w/ tremors and shaking of his "entire body" and worsened
chest discomfort of the same quality, now [**2180-7-24**] in severity.
Reported shallow breathing but denied SOB, nausea, diaphoresis,
vomiting, sweats. Felt cold and was shivering. Wife saw husband
shaking and called 911 and was transported to [**Hospital1 18**].

MEDICAL HISTORY: -cirrhosis [**1-17**] NASH
-HCC s/p liver [**Month/Day (2) **] [**4-19**]
-post-operative course complicated by bile duct ischemia,
strictures, requiring bilateral biliary percutaneous drains,
left drain removed [**2179-1-18**] due to leak
-re-placed on liver [**Year (4 digits) **] list
-cardiac tamponade, required pericardiocentesis in [**8-/2178**]
-DM2 > 10 years
-HTN
-parathyroid adenoma s/p parathyroidectomy [**8-21**]
-CRI, recent baseline cr 1.6-1.9, from DM and HTN
-Squamous cell carcinoma in situ of face

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. cilostazol *NF* 100 mg Oral [**Hospital1 **]
2. Ezetimibe 10 mg PO DAILY
3. Felodipine 10 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Lantus *NF* (insulin glargine) 32 Units Subcutaneous QHS
6. insulin lispro *NF* 15 Units Subcutaneous QID
Titrate to meal time FS
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
10. Rifampin 300 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 7 mg PO Q12H
14. Terazosin 10 mg PO HS
15. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
16. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
17. Ursodiol 600 mg PO QAM
18. Valsartan 320 mg PO DAILY
19. Vitamin D [**2169**] UNIT PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. naltrexone *NF* 50 mg Oral DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: T= afebrile BP= 120/65 HR= 89 RR= 17 O2 sat= 97% on 2L
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site w/ dressing c/d/i. No hematoma or
bruit. No c/c/e.
SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT

FAMILY HISTORY: Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.

SOCIAL HISTORY: Very rare Alcohol use, stopped smoking [**2148**]. Retired, was
previously director of Health Services for the Prison Service.
He has three children, and is married
Bloodstream infection due to central venous catheter,Acute myocardial infarction of other anterior wall, initial episode of care,Sepsis,Septicemia due to gram-negative organism, unspecified,Acute kidney failure with lesion of tubular necrosis,Liver replaced by transplant,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified pruritic conditions,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled
Blood inf dt cen ven cth,AMI anterior wall, init,Sepsis,Gram-neg septicemia NOS,Ac kidny fail, tubr necr,Liver transplant status,Hyposmolality,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Hyperlipidemia NEC/NOS,Long-term use of insulin,Abn react-procedure NEC,Pruritic conditions NEC,DMII renl nt st uncntrld
Admission Date:  [**2182-8-25**]              Discharge Date:   [**2182-9-1**]

Date of Birth:  [**2111-7-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Tremors, chest pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization

History of Present Illness:
77 yo M w/ h/o DM type 2, HTN, dyslidemia, NASH cirrhosis/HCC
s/p liver [**First Name3 (LF) **] who presents w/ tremors and chest pain. Pt
reports was in usual state of health until around 11:30pm night
prior to presentation. At that time noted "rope-like" pain
around his chest while watching TV on the couch. Pain lessened
and he was able to go upstairs and go to sleep. He awoke 1 hour
later w/ tremors and shaking of his "entire body" and worsened
chest discomfort of the same quality, now [**2180-7-24**] in severity.
Reported shallow breathing but denied SOB, nausea, diaphoresis,
vomiting, sweats. Felt cold and was shivering. Wife saw husband
shaking and called 911 and was transported to [**Hospital1 18**].

In the ED, initial vitals were 98.1 95 112/55 14 99% RA. Pt
initially reported tremors and chest pain w/ onset in ED, but on
further questioning noted that CP may have started at home. EKG
was done which showed ST elevations in I, aVL, and V2 w/
infero-lateral ST depressions. Patient was given aspirin 325,
heparin bolus, and nitroglycerin and immediately transported to
the cath lab for STEMI. Labs were notable negative troponin and
creatinine of 2.0.

In the cath lab, patient recieved 600 mg of plavix and 5 mg of
lopressor. Cath was notable for right dominant system w/ 100%
occlusion of mid LAD which was stented w/ a BMS. Also showed 70%
LCx lesion and diffuse disease of the RCA- 50-60%. Pt tolerated
the procedure well and was transported to the CVICU.

On arrival to the floor, patient appeared comfortable and denied
any symptoms of CP, SOB, abd pain, nausea or vomiting. Reported
a little bit of "acid taste" in his mouth.


Past Medical History:
-cirrhosis [**1-17**] NASH
-HCC s/p liver [**Month/Day (2) **] [**4-19**]
-post-operative course complicated by bile duct ischemia,
strictures, requiring bilateral biliary percutaneous drains,
left drain removed [**2179-1-18**] due to leak
-re-placed on liver [**Year (4 digits) **] list
-cardiac tamponade, required pericardiocentesis in [**8-/2178**]
-DM2 > 10 years
-HTN
-parathyroid adenoma s/p parathyroidectomy [**8-21**]
-CRI, recent baseline cr 1.6-1.9, from DM and HTN
-Squamous cell carcinoma in situ of face


Social History:
Very rare Alcohol use, stopped smoking [**2148**]. Retired, was
previously director of Health Services for the Prison Service.
He has three children, and is married


Family History:
Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.


Physical Exam:
ADMISSION EXAM:
VS: T= afebrile BP= 120/65 HR= 89 RR= 17 O2 sat= 97% on 2L
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site w/ dressing c/d/i. No hematoma or
bruit. No c/c/e.
SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT

DISCHARGE EXAM:
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site c/d/i. No hematoma or bruit. No c/c/e.

SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT


Pertinent Results:
ADMISSION LABS:
[**2182-8-25**] 08:35PM   GLUCOSE-288* UREA N-41* CREAT-2.0* SODIUM-134
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-19* ANION GAP-15
[**2182-8-25**] 08:35PM   ALT(SGPT)-60* AST(SGOT)-156* CK(CPK)-633* ALK
PHOS-100 TOT BILI-4.6*
[**2182-8-25**] 08:35PM   CK-MB-55* MB INDX-8.7* cTropnT-5.01*
[**2182-8-25**] 08:35PM   %HbA1c-6.8* eAG-148*
[**2182-8-25**] 08:35PM   tacroFK-6.5
[**2182-8-25**] 08:35PM   WBC-5.5 RBC-3.32* HGB-10.9* HCT-32.9* MCV-99*
MCH-32.9* MCHC-33.3 RDW-15.6*
[**2182-8-25**] 12:36PM   GLUCOSE-274* LACTATE-1.7 K+-3.5
[**2182-8-25**] 12:36PM   freeCa-1.18
[**2182-8-25**] 12:09PM   CK-MB-56* MB INDX-7.3* cTropnT-2.98*
[**2182-8-25**] 05:41AM   CK(CPK)-34*
[**2182-8-25**] 05:41AM   cTropnT-0.01
[**2182-8-25**] 05:41AM   CK-MB-2

Left Heart Catheterization [**2182-8-25**]: R dominant system. LMCA w/
mild disease. LAD w/ 100% mid stenosis --> stented (BMS) --> 0%
residual; LCX: separate ostia from right cusp --> 70% mid; RCA:
50-60% disease, diffuse.

2-D ECHOCARDIOGRAM [**2181-8-25**]:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). The right ventricular
cavity is mildly dilated The aortic root is mildly dilated at
the sinus level. The ascending aorta and aortic arch are mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.

PERTINENT DISCHARGE LABS:

[**2182-9-1**] 07:10AM BLOOD WBC-4.4 RBC-2.69* Hgb-9.1* Hct-26.3*
MCV-98 MCH-33.6* MCHC-34.4 RDW-15.6* Plt Ct-109*
[**2182-9-1**] 07:10AM BLOOD Glucose-126* UreaN-65* Creat-2.6* Na-134
K-4.2 Cl-105 HCO3-16* AnGap-17
[**2182-9-1**] 07:10AM BLOOD ALT-38 AST-49* AlkPhos-515* TotBili-4.5*
[**2182-9-1**] 07:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.5

Brief Hospital Course:
71 yo M w/ h/o NASH cirrhosis and HCC s/p liver [**Month/Day/Year **], DM
type 2, HTN, and dyslipidemia who presented w/ tremors and CP,
found to have STEMI.

#) Anterior STEMI: Pt presented w/vague h/o CP and was found to
have ST elevations in V1-V2 on EKG w/ reciprocal lateral
depressions. TnT on presentation in ED was negative, but
subsequently peaked at 5.63 and MB peaked at 56 during his
hospitalization.  He was loaded with plavix 600mg and taken
urgently to the cath lab and found to have 100% stenosis of the
mid-LAD and 70% stenosis of the mid-circumflex.  This was
treated with a BMS to the mid-LAD.  Repeat echo showed mild
symmetric left ventricular hypertrophy with preserved regional
and global biventricular systolic function (EF>55%). Dilated
thoracic aorta. Mild mitral regurgitation. Borderline pulmonary
artery systolic hypertension.  He was also treated medically
with Aspirin (325mg), Prasugrel 10mg QD, Atorvastatin (ok to use
high dose, per Hepatology), and Metoprolol 25mg PO BID, and
continued his home Terazosin 10mg QHS and cilostazol 100mg PO
BID.

#) CKD: Pt w/ CKD likely [**1-17**] to DM type 2 w/ creatinine at
baseline of 2.0. Did receive 110 mL of contrast during cath and
concern for development of contrast induced nephropathy.  He was
given IVF, diuretics were held, and all medications were renally
dosed.  His Cr increased to 3.7 during this admission, in the
setting of getting IV contrast during the cath.  Nephrology was
consulted and thought this was likely [**1-17**] IV contrast
nephropathy.  He was treated with IVF and then diuresis and Cr
was 2.6 on discharge and will be reevaluated  on [**9-4**] at his
cardiology f/u appointment.

#) On [**8-28**] he spiked a fever to 102.1 and c/o shaking and
chills.  Blood and urine cx were sent and his plasmapheresis
line was removed.  The catheter tip and blood cx gram stains
were positive for GNR and grew out Enterobacter cloaca in
culture sensitive to Ciprofloxacin.  He was initially treated
with Cefepime and meropenem after consultation with Infectious
Disease.  He will be treated for a total of 14 days of
Ciprofloxacin to be discontinued on [**9-10**].

#) NASH Cirrhosis s/p Liver [**Month/Year (2) 1326**]: s/p cadaveric liver
[**Month/Year (2) **] in [**2175-4-16**]. He is currently a candidate for a second
[**Year (4 digits) **] due to biliary strictures in his transplanted liver
though notes he is low on the list. MELD is 20.  Dr. [**Last Name (STitle) 497**], his
hepatologist was contact[**Name (NI) **] during this admission and was ok with
him being treated with Atorvastatin 80mg daily.  In addition,
tacrolimus was continued with levels checked daily.  Rifampin
and bactrim prophylaxis were also continued.  His liver tests
were monitored and were elevated on admission to ALT/AST of
104/74 and were 62/144 prior to discharge.  He is scheduled to
f/u in [**Name (NI) 1326**] [**Hospital 3585**] clinic.

#)HTN:  His BP remained stable during this admission.  He was
continued on metoprolol 50 mg [**Hospital1 **] and valsartan 320 mg daily.
His home medications of Terazosin and Cilostazol were also
continued as mentioned above.

#)Dyslipidemia: switch from Simvastatin to Atorvastatin 80 in
setting of acute MI.  Zetia was discontinued on this admission.
On this admission, his total cholesterol was 92, HDL 15, LDL 62.

#)DM type 2: Insulin dependent. Historically A1c's have been
well controlled and was 6.8% on this admission.  Glargine was
continued during this admission and he was placed on a sliding
scale for meal coverage.

#)Pruritus: Believed secondary to biliary strictures in
transplanted liver. Is on plasmapheresis twice weekly for
symptom relief.  Dr. [**Last Name (STitle) **] was updated and he agreed that homoe
ursodiol and naltrexone be continued while inpatient.

#)PAD: home cilostazol 100 mg [**Hospital1 **] was continued and aspirin 325
mg daily was also given.

#)PROPHYLAXIS:  He was treated prophylactically with Heparin SQ
and a Senna/Colace bowel regimen.

CODE: Full (confirmed w/ pt)

TRANSITIONAL:
- [**Last Name (un) **] follow up for better blood sugar control
- Mildly dilated ascending aorta on Echo, recommend f/u echo in
[**1-18**] years
- Start ACEI/[**Last Name (un) **] once renal function improved (was on Valsartan
320mg QD prior to admission)


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. cilostazol *NF* 100 mg Oral [**Hospital1 **]
2. Ezetimibe 10 mg PO DAILY
3. Felodipine 10 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Lantus *NF* (insulin glargine) 32 Units Subcutaneous QHS
6. insulin lispro *NF* 15 Units Subcutaneous QID
Titrate to meal time FS
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
10. Rifampin 300 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 7 mg PO Q12H
14. Terazosin 10 mg PO HS
15. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
16. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
17. Ursodiol 600 mg PO QAM
18. Valsartan 320 mg PO DAILY
19. Vitamin D [**2169**] UNIT PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. naltrexone *NF* 50 mg Oral DAILY


Discharge Medications:
1. cilostazol *NF* 100 mg Oral [**Hospital1 **] Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
2. Multivitamins 1 TAB PO DAILY
3. naltrexone *NF* 50 mg Oral DAILY
4. Omeprazole 20 mg PO DAILY
5. Rifampin 300 mg PO Q12H
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. Terazosin 10 mg PO HS
8. Ursodiol 900 mg PO QAM
9. Ursodiol 600 mg PO QPM
10. Vitamin D [**2169**] UNIT PO DAILY
11. Nitroglycerin SL 0.4 mg SL PRN chest pain or SOB
RX *nitroglycerin 0.4 mg 1 Tablet sublingually as needed for
chest pain Disp #*50 Tablet Refills:*0
12. Prasugrel 10 mg PO DAILY
start in AM on [**2182-8-26**]
RX *prasugrel [Effient] 10 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
14. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Finasteride 5 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
hold for sbp<110, hr<60
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
18. Tacrolimus 7 mg PO Q12H
19. Ciprofloxacin HCl 500 mg PO Q24H Duration: 14 Days
last day [**9-10**]
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
20. Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
21. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Acute ST Elevated Myocardial Infarction (Heart Attack)

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


Discharge Instructions:
Dear Mr. [**Known lastname 4541**],

You were admitted to [**Hospital1 69**] after
presenting with complaints of tremors and chest pain.  You were
diagnosed with a heart attack and we urgently performed a
procedure to open the blocked artery by placing a stent in the
artery to keep it open.  You were started on a new medication
called Prasugrel which is similar to a "super aspirin" and helps
to keep the artery open after having a stent placed.  It is very
important that you take this new medication daily until
instructed to stop by your cardiologist. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]
or stop taking prasugrel unless Dr. [**Last Name (STitle) 171**] tells you it is OK.

You developed an infection of your blood stream from the line
used for Pheresis (done for your itching). This line was removed
and you will need to take an antibiotic, Ciprofloxacin 500mg for
until  [**2182-9-10**]. Please call Dr [**Last Name (STitle) 171**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) 26187**] notice any fevers, chills, rashes or any other concerning
symptoms.
Your kidney function worsened after receiving IV contrast, used
to help open the blocked artery in your heart. Your kidney
function improved with IV fluids and with time. You should have
labs checked to assess kidney function two days after discharge.
Results will be sent to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].

The following changes were made to your medications:

START:
Prasugrel 10mg / day
Ciprofloxacin 500mg once/day until [**2182-9-10**]
Atorvastatin 80 mg once daily
Aspirin 325mg once daily
Nitroglycerin 0.4mg SL

STOP:
Simvastatin 10mg daily
Ezetimibe 10mg daily
Felodipine 10mg daily
Triamterene/Hydrocholorothiazide
Valsartan

INCREASE:
Glargine from 32 units at bedtime to 40 units at bedtime

DECREASE:
Metoprolol 50mg twice daily to Metoprolol 25mg twice daily

Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-9-4**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DERMATOLOGY
When: THURSDAY [**2182-9-5**] at 10:15 AM
With: [**Name6 (MD) 1037**] [**Name8 (MD) 5647**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2182-9-4**] at 11:15 AM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: Wednesday [**2182-9-4**] 1:30pm
**You did have an eye exam scheduled at [**Last Name (un) **] at this time. We
tried hard to get you to see both around the same time but it
wasnt possibl. We rescheduled the eye exam for [**2182-9-5**] at
9:00am. If you have any questions or concerns please call [**Last Name (un) **]
at the above number.
{'Bloodstream infection due to central venous catheter,Acute myocardial infarction of other anterior wall, initial episode of care,Sepsis,Septicemia due to gram-negative organism, unspecified,Acute kidney failure with lesion of tubular necrosis,Liver replaced by transplant,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified pruritic conditions,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}


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: Tremors, chest pain

PRESENT ILLNESS: 77 yo M w/ h/o DM type 2, HTN, dyslidemia, NASH cirrhosis/HCC
s/p liver [**First Name3 (LF) **] who presents w/ tremors and chest pain. Pt
reports was in usual state of health until around 11:30pm night
prior to presentation. At that time noted "rope-like" pain
around his chest while watching TV on the couch. Pain lessened
and he was able to go upstairs and go to sleep. He awoke 1 hour
later w/ tremors and shaking of his "entire body" and worsened
chest discomfort of the same quality, now [**2180-7-24**] in severity.
Reported shallow breathing but denied SOB, nausea, diaphoresis,
vomiting, sweats. Felt cold and was shivering. Wife saw husband
shaking and called 911 and was transported to [**Hospital1 18**].

MEDICAL HISTORY: -cirrhosis [**1-17**] NASH
-HCC s/p liver [**Month/Day (2) **] [**4-19**]
-post-operative course complicated by bile duct ischemia,
strictures, requiring bilateral biliary percutaneous drains,
left drain removed [**2179-1-18**] due to leak
-re-placed on liver [**Year (4 digits) **] list
-cardiac tamponade, required pericardiocentesis in [**8-/2178**]
-DM2 > 10 years
-HTN
-parathyroid adenoma s/p parathyroidectomy [**8-21**]
-CRI, recent baseline cr 1.6-1.9, from DM and HTN
-Squamous cell carcinoma in situ of face

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. cilostazol *NF* 100 mg Oral [**Hospital1 **]
2. Ezetimibe 10 mg PO DAILY
3. Felodipine 10 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Lantus *NF* (insulin glargine) 32 Units Subcutaneous QHS
6. insulin lispro *NF* 15 Units Subcutaneous QID
Titrate to meal time FS
7. Metoprolol Tartrate 50 mg PO BID
8. Omeprazole 20 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5.0
10. Rifampin 300 mg PO Q12H
11. Simvastatin 10 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 7 mg PO Q12H
14. Terazosin 10 mg PO HS
15. testosterone propionate *NF* 1 % Transdermal DAILY
apply as directed to upper back and shoulders
16. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
17. Ursodiol 600 mg PO QAM
18. Valsartan 320 mg PO DAILY
19. Vitamin D [**2169**] UNIT PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. naltrexone *NF* 50 mg Oral DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
VS: T= afebrile BP= 120/65 HR= 89 RR= 17 O2 sat= 97% on 2L
GENERAL: overweight, pleasant gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera icteric. dry MM. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa. No
xanthalesma.
NECK: Supple; unable to appreciate JVP 2/2 habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, somewhat distended w/ mild TTP in [**Name (NI) 5283**]; enlarged
liver; + BS; no rebound or guarding.
EXTREMITIES: R groin site w/ dressing c/d/i. No hematoma or
bruit. No c/c/e.
SKIN: + [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] scar of abdomen, well healed; No stasis
dermatitis, ulcers, spider angiomas, or xanthomas.
PULSES:
Right: Dopplerable DP & PT
[**Name (NI) 2325**]: Dopplerable DP & PT

FAMILY HISTORY: Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.

SOCIAL HISTORY: Very rare Alcohol use, stopped smoking [**2148**]. Retired, was
previously director of Health Services for the Prison Service.
He has three children, and is married 

### Response:
{'Bloodstream infection due to central venous catheter,Acute myocardial infarction of other anterior wall, initial episode of care,Sepsis,Septicemia due to gram-negative organism, unspecified,Acute kidney failure with lesion of tubular necrosis,Liver replaced by transplant,Hyposmolality and/or hyponatremia,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other and unspecified hyperlipidemia,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified pruritic conditions,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled'}
