CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: This is a [**Age over 90 **] year old lady with a history of Afib on Coumadin,
CHF EF 15-20%, MVR with porcine tissue, prior amaurosis and
prior CVA with residual left weakness and right facial droop who
presents with acute onset left sided chest pain. The pain is
localized to left chest, was sharp in nature and constant. The
pain began at 10:30 am while patient was sleeping. The pain was
[**9-23**] at onset and lasted about 2 hours. Worsened with deep
inspiration. It dissipated slowly after being given ASA 81mg x 4
pills prior to arrival of ambulance. The patient denies use of
nitroglycerin. She reports associated shortness of breath with
pain, but denies diaphoresis, palpitations, dizziness, cough,
fevers.
.
.
In the ED, initial vitals were 98.4 62 149/98 20 100%.  Labs and
imaging significant for positive second set of troponin of 0.95
at 5am, proBNP: 2283, INR 1.9, creat 1.5 (at baseline). She was
given Clopidogrel 300 mg in ED and 4 baby ASA at home prior to
arrival to ED. Vitals on transfer were  98.7 ??????F (37.1 ??????C), 64,
RR: 16, BP: 128/67,  Atrial Fibrillation, O2Sat: 98% onRA.
.
On arrival to the floor, patient denies chest pain and is
feeling well.
.
REVIEW OF SYSTEMS
Review of systems is significant for h/o prior stroke, TIA, deep
venous thrombosis, and chronic back pain. ?Daughter reports
noting pink urine x 1 yesterday, however, patient denies
hematuria.
She denies myalgias, cough, hemoptysis, black stools, red
stools, dysuria, nausea, vomiting, abdominal pain. She denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
----Afib on coumadin (goal INR 3)
----CHF/severe valvular cardiomyopathy EF 15-20% on ECHO [**Month (only) **]
[**2175**] [**2-15**] post-op changes from MVR (anterior mitral leaflet and
its chordal attachments were severed w/ post-op ef of 25%)
----Moderate Tricuspid Regurgitation
----s/p MVR w/porcine tissue '[**61**] for MV regurg [**2-15**] MVP
----peripheral vascular disease
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD:  n/a
3. OTHER PAST MEDICAL HISTORY:
-hx of DVT, PE (DVT [**11-19**], PE '[**57**])
-HTN
-Hypothyroidism
-Atrial emboli
-DJD
-CVA p/w slurred speech and facial droop
-CKD, baseline Cr 1.3-1.6

MEDICATION ON ADMISSION: -docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
-senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day)
as needed for constipation.
-aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
-levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
half Tablet Extended Release 24 hr PO at bedtime.
-torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day.
-acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
-carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 5 days.
-Warfarin 5 mg M/F, 6 mg Tu/W/Th/Sa/[**Doctor First Name **]
.
ALLERGIES/INTOLERANCES
ACE inhibitors caused a cough and angiotensin receptor blocker
has caused hypotension, lightheadedness and near syncope.

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: VS: T=.97.8.BP 146/84 HR=.60.RR=.18.O2 sat=  97RA 68kg
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.  +SSA trait.

SOCIAL HISTORY: Patient lives on [**Location (un) 448**] of two-family home; daughter lives
upstairs. Significant support from her children, senior
services. Uses walker to ambulate.
-Tobacco history:  denies
-ETOH: denies
-Illicit drugs: denies
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Personal history of venous thrombosis and embolism,Peripheral vascular disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Late effects of cerebrovascular disease, dysarthria,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other alteration of consciousness,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Disorders of bilirubin excretion,Unspecified acquired hypothyroidism
Subendo infarct, initial,Ac on chr syst hrt fail,Prim cardiomyopathy NEC,Acute kidney failure NOS,Crnry athrscl natve vssl,Atrial fibrillation,Long-term use anticoagul,Heart valve transplant,Hx-ven thrombosis/embols,Periph vascular dis NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Late eff CV-dysarthria,Osteoarthros NOS-unspec,Other alter consciousnes,Adv eff sympatholytics,Dis bilirubin excretion,Hypothyroidism NOS
Admission Date:  [**2176-3-25**]              Discharge Date:   [**2176-4-2**]


Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
chest pain


Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a [**Age over 90 **] year old lady with a history of Afib on Coumadin,
CHF EF 15-20%, MVR with porcine tissue, prior amaurosis and
prior CVA with residual left weakness and right facial droop who
presents with acute onset left sided chest pain. The pain is
localized to left chest, was sharp in nature and constant. The
pain began at 10:30 am while patient was sleeping. The pain was
[**9-23**] at onset and lasted about 2 hours. Worsened with deep
inspiration. It dissipated slowly after being given ASA 81mg x 4
pills prior to arrival of ambulance. The patient denies use of
nitroglycerin. She reports associated shortness of breath with
pain, but denies diaphoresis, palpitations, dizziness, cough,
fevers.
.
.
In the ED, initial vitals were 98.4 62 149/98 20 100%.  Labs and
imaging significant for positive second set of troponin of 0.95
at 5am, proBNP: 2283, INR 1.9, creat 1.5 (at baseline). She was
given Clopidogrel 300 mg in ED and 4 baby ASA at home prior to
arrival to ED. Vitals on transfer were  98.7 ??????F (37.1 ??????C), 64,
RR: 16, BP: 128/67,  Atrial Fibrillation, O2Sat: 98% onRA.
.
On arrival to the floor, patient denies chest pain and is
feeling well.
.
REVIEW OF SYSTEMS
Review of systems is significant for h/o prior stroke, TIA, deep
venous thrombosis, and chronic back pain. ?Daughter reports
noting pink urine x 1 yesterday, however, patient denies
hematuria.
She denies myalgias, cough, hemoptysis, black stools, red
stools, dysuria, nausea, vomiting, abdominal pain. She denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
----Afib on coumadin (goal INR 3)
----CHF/severe valvular cardiomyopathy EF 15-20% on ECHO [**Month (only) **]
[**2175**] [**2-15**] post-op changes from MVR (anterior mitral leaflet and
its chordal attachments were severed w/ post-op ef of 25%)
----Moderate Tricuspid Regurgitation
----s/p MVR w/porcine tissue '[**61**] for MV regurg [**2-15**] MVP
----peripheral vascular disease
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD:  n/a
3. OTHER PAST MEDICAL HISTORY:
-hx of DVT, PE (DVT [**11-19**], PE '[**57**])
-HTN
-Hypothyroidism
-Atrial emboli
-DJD
-CVA p/w slurred speech and facial droop
-CKD, baseline Cr 1.3-1.6

Social History:
Patient lives on [**Location (un) 448**] of two-family home; daughter lives
upstairs. Significant support from her children, senior
services. Uses walker to ambulate.
-Tobacco history:  denies
-ETOH: denies
-Illicit drugs: denies

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.  +SSA trait.

Physical Exam:
VS: T=.97.8.BP 146/84 HR=.60.RR=.18.O2 sat=  97RA 68kg
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with no appreciable JVD but difficult to assess as
pt moving.
CARDIAC: irreg irreg, normal S1, S2. No m/r/g appreciated
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, minimal crackles
at bases L>R,decreased BS at bases BL
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. distal pulses, dp, pt non-palpable
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
.
on DISCHARGE:
VS: tmax 98.3, HR 70-80, BP 110-130/60-80, 20, 95/RA
MS: Sleepy, rouses to voice and follows commands
HEENT: dry MM, OP clear
Neck: supple
CV: irregularly irregular, nls2s2 no mrg
Lungs: from anterior clear but poor inspiratory effort
Abdomen: soft, non-tender, non-distended
neuro: slurred speech unchanged, mild right sided facial droop.
Tongue appears midline.  Increased tone in LUE, some spasticity,
it is flexed (baseline)
Nl tone in RUE. decreased 3-4/5 strength right handgrip and  [**4-18**]
arm raise, 5+ on left. Toes are equivocal. 4/5 strength b/l [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: warm, well perfused, no edema
psych: oriented to person and place. On [**4-1**] was also oriented
to time. On [**4-1**] could do full days of week forward and not
backwards. On [**4-2**] can only do Monday and Tuesday with
prompting.

Pertinent Results:
Admission labs:

[**2176-3-24**] 11:04PM BLOOD WBC-6.4 RBC-4.83 Hgb-13.9 Hct-39.0
MCV-81* MCH-28.7 MCHC-35.6* RDW-16.3* Plt Ct-486*
[**2176-3-24**] 11:04PM BLOOD Neuts-63.2 Lymphs-28.8 Monos-4.5 Eos-2.6
Baso-1.0
[**2176-3-24**] 11:04PM BLOOD PT-19.7* PTT-36.5 INR(PT)-1.9*
[**2176-3-24**] 11:04PM BLOOD Glucose-147* UreaN-34* Creat-1.5* Na-137
K-4.4 Cl-98 HCO3-27 AnGap-16
[**2176-3-25**] 05:00AM BLOOD CK(CPK)-247*
[**2176-3-24**] 11:04PM BLOOD proBNP-2283*
[**2176-3-26**] 06:40AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2

Pertinent labs during hospital course:

[**2176-3-30**] 09:45AM BLOOD ALT-17 AST-49* AlkPhos-55 TotBili-2.5*
[**2176-3-24**] 11:04PM BLOOD cTropnT-<0.01
[**2176-3-25**] 05:00AM BLOOD CK-MB-23* MB Indx-9.3* cTropnT-0.95*
[**2176-3-25**] 07:45PM BLOOD CK-MB-23* MB Indx-7.3* cTropnT-2.13*
[**2176-3-26**] 06:40AM BLOOD CK-MB-10 MB Indx-5.6 cTropnT-1.81*
[**2176-3-26**] 09:40AM BLOOD CK-MB-9 cTropnT-1.76*
[**2176-3-26**] 05:14PM BLOOD CK-MB-7 cTropnT-1.61*
[**2176-3-27**] 04:31AM BLOOD CK-MB-6 cTropnT-1.37*
[**2176-4-1**] 06:15AM BLOOD CK-MB-4 cTropnT-0.48*
[**2176-4-1**] 04:55PM BLOOD CK-MB-3 cTropnT-0.42*
[**2176-3-27**] 04:50AM BLOOD Type-[**Last Name (un) **] pO2-21* pCO2-54* pH-7.37
calTCO2-32* Base XS-2
[**2176-3-27**] 04:50AM BLOOD Lactate-1.8
[**2176-4-1**] 06:15AM BLOOD Hapto-116
[**2176-3-30**] 09:45AM BLOOD TSH-1.7

Discharge labs:

[**2176-4-2**] 06:50AM BLOOD WBC-8.0 RBC-4.52 Hgb-12.7 Hct-39.0 MCV-86
MCH-28.1 MCHC-32.5 RDW-16.6* Plt Ct-577*
[**2176-4-2**] 06:50AM BLOOD PT-30.9* PTT-49.2* INR(PT)-3.0*
[**2176-4-2**] 06:50AM BLOOD Glucose-95 UreaN-24* Creat-1.3* Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
[**2176-4-1**] 06:15AM BLOOD ALT-14 AST-42* LD(LDH)-372* CK(CPK)-333*
AlkPhos-54 TotBili-1.6* DirBili-0.4* IndBili-1.2
[**2176-4-1**] 04:55PM BLOOD CK(CPK)-260*
[**2176-4-2**] 06:50AM BLOOD LD(LDH)-313* TotBili-1.5
[**2176-4-2**] 06:50AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.4

Microbiology:
all negative cultures- finalized
[**2176-3-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2176-3-27**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2176-3-26**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2176-3-26**] URINE URINE CULTURE-FINAL INPATIENT \

Radiology:
Final Report
AP CHEST, 12:56 P.M., [**2176-4-1**]

HISTORY: [**Age over 90 **]-year-old woman with atrial fibrillation, on
Coumadin. MVR and
CVAs. Recent MI.

IMPRESSION: AP chest compared to [**3-24**] and 13:

Severe cardiomegaly is chronic. There is no longer any pulmonary
edema.
Pleural effusions are small if any. No focal pulmonary
abnormality.

DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: MON [**2176-4-1**] 4:55 PM

  Imaging Lab


Final Report
INDICATION: [**Age over 90 **]-year-old woman with altered mental status, any
evidence of
stroke or hemorrhage.

COMPARISON: CT head on [**2176-3-26**] at 20:49 and 9:02.

TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered. Study is severely limited due to
patient motion
causing artifact.

FINDINGS: Within the limitation of motion artifact, there is no
gross
evidence of hemorrhage, edema, mass, mass effect, or large
vascular
territorial infarction. The previously seen areas of
encephalomalacia in the
right frontoparietal, left occipital, and cerebellar hemispheres
are
unchanged. The chronic lacunar infarct in the left putamen is
unchanged. The
periventricular and centrum semiovale hypodensities consistent
with small
vessel ischemic disease are unchanged. The ventricles and sulci
are mildly
prominent consistent with age-related atrophy. Visualized
paranasal sinuses
and mastoid air cells are well aerated. No fracture is
identified.

IMPRESSION:
1. Limited study due to motion artifact. Within the limitation,
there is no
gross evidence of hemorrhage or acute infarction.

2. Unchanged areas of encephalomalacia in right frontoparietal,
left
occipital, and cerebellar hemispheres.

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


DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: [**Doctor First Name **] [**2176-3-28**] 1:43 PM

[**2176-3-27**]

FINDINGS:
ABNORMALITY #1: The background activity is mostly low voltage
slow [**7-21**]
Hz alpha rhythm posteriorly.
ABNORMALITY #2: Excess diffuse theta activity was present
diffusely.
BACKGROUND: Waking background is characterized by a low voltage
and
slow [**7-21**] Hz posterior dominant rhythm. Symmetric [**5-23**] mcV beta
activity
is present, maximal over bilateral frontal regions. Excess
diffuse
admixed theta activity was present throughout the record.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation is
not
performed.
SLEEP: No sleep morphology was recorded.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm
with an average rate of 70 bpm.
IMPRESSION: This is an abnormal portable EEG because of mild
diffuse
background slowing. These findings are indicative of mild
diffuse
encephalopathy which is etiologically non-specific. There were
no focal
asymmetries or epileptiform features.

Final Report
INDICATION: [**Age over 90 **]-year-old woman with history of CVA, AFib, and
NSTEMI on
heparin, aspirin, Plavix, now with altered mental status,
evaluate for acute
stroke.

COMPARISON: CT head on [**2176-2-15**] and MR head on [**2175-8-6**].

TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administered.

FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or
acute territorial infarction. The changes of encephalomalacia in
the right
frontoparietal region and left occipital lobe from previous
infarctions are
similar compared to [**2176-2-15**]. The areas of focal
encephalomalacia in
the cerebellar hemispheres are unchanged. The chronic lacunar
infarct in the
left putamen is unchanged. Again seen are confluent
periventricular and
centrum semiovale hypodensities consistent with the sequelae of
chronic small
vessel ischemic disease. The ventricles and sulci are mildly
prominent
consistent with age-related atrophy. Visualized paranasal
sinuses and mastoid
air cells are well aerated. No fracture is identified.

IMPRESSION:
1. No acute intracranial process.
2. Unchanged areas of encephalomalacia in the right
frontoparietal, and left
occipital lobes from prior infarctions. Also unchanged focal
encephalomalacia
in cerebellar hemispheres.
3. Chronic small vessel ischemic disease.

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


DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: TUE [**2176-3-26**] 4:36 PM

Cardiovascular Report ECG Study Date of [**2176-3-26**]  7:47:42 AM


Atrial fibrillation with controlled ventricular response. Left
bundle-branch
block. Compared to the previous tracing of [**2176-3-25**] no diagnostic
interim
change.


Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]


[**2176-4-2**] 01:10PM BLOOD PTT-72.3*

Brief Hospital Course:
This is a [**Age over 90 **] year old lady with a history of Afib on Coumadin,
CHF EF 15-20%, MVR with porcine tissue, prior amaurosis and
prior CVA with residual left weakness and right facial droop who
presents with acute onset left sided chest pain.
.
# AMS
On morning of HD 2 patient nursing staff and family report
patient experienced dizziness when standing and had to be helped
back into bed by nurse and daughter. Patient's daughter also
reported patient was slurring her speech and was concerned that
this presentation was similar to prior stroke. On evaluation,
patient's speech was discernable w/ no significant dysarthria
and patient was responsive to commands with no new deficits on
neurologic exam. She did complain however of some chest
"soreness" but it was difficult to delineate chest pain from
discomfort of tele box/tele pads. While patient had no new
findings on neuro exam, flucuating mental status and family
report of similar presentation with prior CVA in the setting of
anticoagulation and dual antiplatelet therapy was concerning for
possible stroke. History difficult to clarify with patient and
primary process  more concerning for chest pain and cardiac
event with resulting decreased attention rather than CVA.
Nonetheless, given above mentioned factors and prior h/o CVA was
concerning enough to consult neurology for further evaluation.
After neuro eval, code stroke was called. Stat head CT obtained
which was negative for hemorrhagic stroke. Patient's speech
difficulties resolved shortly raising question of TIA vs
reactivation of old stroke symptoms in the setting of
physiologic stress.
Pt was transferred to the ICU for delerium.  Her work up
included: negative infectious w/o (blood, urine, CXR), normal
electrolytes, down trending cardiac enzymes, 20min EEG w/o
evidence of seizure.  A repeat head CT was also performed that
was unchanged.  Pt improved once transfered out to the floor on
[**3-28**], however continued to experience waxing and [**Doctor Last Name 688**]
alertness, being most alert in the afternoons.  Likely source
for acute change of unresponsiveness includes benzo's vs
possible stroke. Given that management would not change and
patient improved, MRI was not pursued. She was evaluated by
geriatrics who agreed with assessment. We think that her
inability to resume her baseline mental status is likely due to
either a possible stroke or to delerium in the setting of a
NSTEMI and multiple medicatl problems.

# CORONARIES: NSTEMI
Chest pain of sudden onset with positive troponins and no
significant changes on EKG (although difficult to interpret in
the setting of LBBB) is consistent with NSTEMI. Patient
anticoagulated on warfarin with INR of 1.9. Given 300mg plavix
and ASA 325mg in ED. Risk factors for CAD include h/o HTN.
Patient's LDL was 38 and A1c was 4.3 in 7/[**2175**]. Upon transfer to
ICU, patient was continued on heparin gtt and aspirin.  Plavix
was not restarted and confirmed with cardiology that she should
be on aspirin and coumadin on discharge.  Her metoprolol and
losartan were held because of SBP 90s, while patient was NPO and
delerius.  Patient was continued on heparin gtt given h/o
strokes, afib, and LV thrombus and is currently bridging to
coumadin. She should restart losartan as an outpatient. There
was a concern that metoprolol could have contributed to mental
status changes. If blood pressure still stable on losartan and
HR is >70, should readdress attempting to start metoprolol.
Cardiology felt that she would not benefit greatly from
intervention and should be medically managed. She should
continue on statin therapy.

# elevated bili: Patient had elevation in indirect bili and LDH
suggesting hemolysis however Hct Stable. Platelets normal to
suggest not TTP. Has had elevated bili in the past, ? clots with
lysis as was recently off anticoagulation versus hemolysis from
valve (though is porcine, not mechanical). It resolved
spontaneously.

# Acute on chronic renal insufficiency: Resolved. Likely
prerenal due to hypotension and poor oral intake.

# hypoxia: Stable on room air with clear CXR. [**Month (only) 116**] have been due
to aspiration or somnolence with atelectasis.

# CHF. EF 20% 2/[**2176**]. Currently dry or euvolemic. Holding
torsemide. Consideration should be given to restarting if weight
increases more than 3 lbs

# Atrial fibrillation. Rate controlled. Now off metoprolol.
Continuing heparin bridge (last PTT attached at goal), at 550
unit/hour to coumadin.

# Hypothyroidism: Continued levothyroxine

# PVD: Continued ASA/Statin

CODE: Full code (confirmed)

EMERGENCY CONTACT:  [**First Name8 (NamePattern2) **] [**Known lastname **], daugher, H[**Telephone/Fax (1) 100347**],
C[**Telephone/Fax (1) 100348**]; [**Hospital1 **], daughter, [**Telephone/Fax (1) 100349**], H [**Telephone/Fax (1) 100350**];
HCP: son- [**Name (NI) 449**] [**Name (NI) 100351**]: [**Telephone/Fax (1) 100352**]
[**Doctor Last Name 449**] is HCP and [**Name (NI) **] is the back-up.

Transitional issues
- patient on heparin drip for 48 hours bridge from morning of
[**4-2**] as long as INR on coumadin 2.5-3.5
- restart losartan at low dose if SBPs >110s and consider
restarting metoprolol after that
- restart torsemide for weight gain more than 3 lbs or hypoxia
suggesting pulmonary edema
- would avoid ativan and use haldol 2.5mg prn for agitation if
recurs, however she has not needed it

Medications on Admission:
-docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
-senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day)
as needed for constipation.
-aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
-levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
half Tablet Extended Release 24 hr PO at bedtime.
-torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day.
-acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
-carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 5 days.
-Warfarin 5 mg M/F, 6 mg Tu/W/Th/Sa/[**Doctor First Name **]
.
ALLERGIES/INTOLERANCES
ACE inhibitors caused a cough and angiotensin receptor blocker
has caused hypotension, lightheadedness and near syncope.


Discharge Medications:
1. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
5. heparin IV sliding scale
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
8. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary diagnosis:
non-ST elevation myocardial infarction
congestive heart failure

Secondary diagnoses: hypertension, atrial fibrillation


Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Clear and coherent, mildly slurred speech

Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Ms [**Known lastname **],

You were admitted for evaluation of chest pain. While you were
here, you had a heart attack (NSTEMI) which you were given
medications for.  The cardiologists and your primary care doctor
do NOT think that you would benefit from a procedure to evaluate
your heart.

While you were here, your thinking worsened and you were sent to
the intensive care unit for mental status changes. You had
multiple catscans of your head and there was no new large
stroke. You may have had a smaller stroke. You were seen by
neurology who did not think that you were having a seizure. The
changes in your thinking may also be from a delerium which
worsened from your heart illness and being in a place unfamiliar
to you.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

While you were here, some of your medications were changed:
INCREASE aspirin from 81mg to 325mg daily
STOP losartan 25mg daily
STOP metoprolol succinate 25mg daily
STOP torsemide 30mg daily

Your facility can consider restarting these medications as
indicated.

Followup Instructions:
You should follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from [**Hospital1 100**] MACU.

Department: NEUROLOGY
When: TUESDAY [**2176-4-30**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2176-5-15**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], 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: [**Hospital3 1935**] CENTER
When: MONDAY [**2176-6-3**] at 1 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Personal history of venous thrombosis and embolism,Peripheral vascular disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Late effects of cerebrovascular disease, dysarthria,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other alteration of consciousness,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Disorders of bilirubin excretion,Unspecified acquired hypothyroidism'}


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: This is a [**Age over 90 **] year old lady with a history of Afib on Coumadin,
CHF EF 15-20%, MVR with porcine tissue, prior amaurosis and
prior CVA with residual left weakness and right facial droop who
presents with acute onset left sided chest pain. The pain is
localized to left chest, was sharp in nature and constant. The
pain began at 10:30 am while patient was sleeping. The pain was
[**9-23**] at onset and lasted about 2 hours. Worsened with deep
inspiration. It dissipated slowly after being given ASA 81mg x 4
pills prior to arrival of ambulance. The patient denies use of
nitroglycerin. She reports associated shortness of breath with
pain, but denies diaphoresis, palpitations, dizziness, cough,
fevers.
.
.
In the ED, initial vitals were 98.4 62 149/98 20 100%.  Labs and
imaging significant for positive second set of troponin of 0.95
at 5am, proBNP: 2283, INR 1.9, creat 1.5 (at baseline). She was
given Clopidogrel 300 mg in ED and 4 baby ASA at home prior to
arrival to ED. Vitals on transfer were  98.7 ??????F (37.1 ??????C), 64,
RR: 16, BP: 128/67,  Atrial Fibrillation, O2Sat: 98% onRA.
.
On arrival to the floor, patient denies chest pain and is
feeling well.
.
REVIEW OF SYSTEMS
Review of systems is significant for h/o prior stroke, TIA, deep
venous thrombosis, and chronic back pain. ?Daughter reports
noting pink urine x 1 yesterday, however, patient denies
hematuria.
She denies myalgias, cough, hemoptysis, black stools, red
stools, dysuria, nausea, vomiting, abdominal pain. She denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
----Afib on coumadin (goal INR 3)
----CHF/severe valvular cardiomyopathy EF 15-20% on ECHO [**Month (only) **]
[**2175**] [**2-15**] post-op changes from MVR (anterior mitral leaflet and
its chordal attachments were severed w/ post-op ef of 25%)
----Moderate Tricuspid Regurgitation
----s/p MVR w/porcine tissue '[**61**] for MV regurg [**2-15**] MVP
----peripheral vascular disease
-CABG: n/a
-PERCUTANEOUS CORONARY INTERVENTIONS: n/a
-PACING/ICD:  n/a
3. OTHER PAST MEDICAL HISTORY:
-hx of DVT, PE (DVT [**11-19**], PE '[**57**])
-HTN
-Hypothyroidism
-Atrial emboli
-DJD
-CVA p/w slurred speech and facial droop
-CKD, baseline Cr 1.3-1.6

MEDICATION ON ADMISSION: -docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
-senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day)
as needed for constipation.
-aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO
DAILY (Daily).
-levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
-losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
half Tablet Extended Release 24 hr PO at bedtime.
-torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day.
-acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
-carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 5 days.
-Warfarin 5 mg M/F, 6 mg Tu/W/Th/Sa/[**Doctor First Name **]
.
ALLERGIES/INTOLERANCES
ACE inhibitors caused a cough and angiotensin receptor blocker
has caused hypotension, lightheadedness and near syncope.

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: VS: T=.97.8.BP 146/84 HR=.60.RR=.18.O2 sat=  97RA 68kg
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.  +SSA trait.

SOCIAL HISTORY: Patient lives on [**Location (un) 448**] of two-family home; daughter lives
upstairs. Significant support from her children, senior
services. Uses walker to ambulate.
-Tobacco history:  denies
-ETOH: denies
-Illicit drugs: denies 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Long-term (current) use of anticoagulants,Heart valve replaced by transplant,Personal history of venous thrombosis and embolism,Peripheral vascular disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Late effects of cerebrovascular disease, dysarthria,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other alteration of consciousness,Sympatholytics [antiadrenergics] causing adverse effects in therapeutic use,Disorders of bilirubin excretion,Unspecified acquired hypothyroidism'}
