CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 61yo F w/ hx of HTN, hyperlipidemia, DM, CAD, s/p MI and CABG x
3 (LIMA-LAD, SVG-OM, SVG-RCA) in [**2097**], s/p known occluded vein
grafts, s/p cardiac cath in [**2103**] c/b dissection of the LCx and
s/p 2
Cypher DES placed. Pt is s/p prosthetic [**Year (4 digits) 1291**] in [**1-/2107**] for AS and
underwent cath prior to that surgery and had a BMS to the left
subclavian artery.  Most recently [**2108-10-1**] had 80% ostial LAD
lesions and got BMS to proximal LAD.
.
Patient reports worsening chest pain over the last few months,
and reports using nitro multiple times a day.  This pain occurs
with rest and with activity.  She describes intermittent chest
pain over past 3 days which became constant, associated with
diaphoresis.  On the day of presentation, the patient had sudden
onset of substernal chest pain while walking, and experienced
associated shortness of breath, palpitations, diaphoresis.  She
denies any presyncopal symptoms, nausea, or vomiting.  Despite
[**3-31**] does of NTG, the pain was did not improve, and the patient
activated EMS.
.
When EMS arrived in the field, HR was 210, BP 160/110.  Pt was
given SL NTG and Lopressor 5mg IV X 3 which brought rate to
140s-150s.  On presentation to ED, initial vitals were BP
144/106, HR 85, RR 20, 98% on 2L.  Pt received several mg IV
morphine, nitro 0.4mg LS, ativan 0.5mg IV, then 1mg IV, dilauded
1mg X 2, ASA 325, Lopressor 5mg IV X 2.  Was started on Nitro
gtt which was increased to 200mcg/min. Despite these
medications, the patient only had mild improvement of symptoms.
Initial ECG showed afib with new LBBB pattern, ST depressions in
V5, V6.  Given unremitting chest pain and positive cardiac
markers, the patient was admitted to the CCU for further
monitoring with planned cath in the morning.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cath [**2108-10-1**]:
R-dominant 3 vessel native disease.
LMCA with dual ostia
Ostial LAD had an 80% stenosis with poor perfusion of D1 and s1,
got BMS to proximal LAD
Stenosis in the LAD distal to the takeoff of D1 that impairs
flow from D1 to the LAD
LCX has a aproximal 40% stenosis
SVGs were known to be occluded
selective conduit arteriography revealed a patent LIMA to LAD
The subclavian artery had a 30% in stent restenosis

MEDICATION ON ADMISSION: Lasix 20mg PO qday
Omeprazole 20mg PO qday
Rosuvastatin 20mg PO qday
Levothyroxine 50mcg PO qday
Imdur 120mg PO qday
Duloxetine 60mg PO qday
Colace 100mg PO BID
Ferrous Sulfate 325mg PO qday
Maalox 30ml PO q12hours PRN
Morphine 15mg PO q12 hours
Trazodone 150-200mg PO qHS PRN insomnia
Ascorbic Acid 1000mg PO qday
Clopidogrel 75mg PO qday
Morphine 30mg PO q4 hours PRN X 10 days
Lisinopril 80mg PO qday
NTG 0.4mg SL 1-2 tabs q6hours PRN
Toprol XL 300mg PO qday
Warfarin 7.5 g PO qday
Acetaminophen 325 - 650mg PO q6H PRN

ALLERGIES: Ambien / Percocet / Iodine; Iodine Containing

PHYSICAL EXAM: VS: T99.8 BP 136/57 HR 106 O2 98% on 2L
GENERAL: WDWN female crying, anxious, but appears comfortable
Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No dentition.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly, irregular rhytyth, tachycardic, normal S1,
S2. [**2-1**] low pitched murmur heard best LLSB and apex.  [**1-1**] slight
higher pitched murmur at LUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

SOCIAL HISTORY: No tobacco or alcohol use.  Lives alone, has 3 children.
Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other left bundle branch block,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Atherosclerosis of other specified arteries,Depressive disorder, not elsewhere classified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Atrial fibrillation,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Insomnia, unspecified,Old myocardial infarction,Heart valve replaced by other means,Other acquired absence of organ,Long-term (current) use of anticoagulants,Acquired absence of both cervix and uterus,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Comp-oth cardiac device,Subendo infarct, initial,Crn ath atlg vn bps grft,Pneumonia, organism NOS,CHF NOS,Left bb block NEC,Iron defic anemia NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Rheumatoid arthritis,Atherosclerosis NEC,Depressive disorder NEC,Myalgia and myositis NOS,Hypothyroidism NOS,Atrial fibrillation,Osteoarthros NOS-unspec,Insomnia NOS,Old myocardial infarct,Heart valve replac NEC,Acq absence of organ NEC,Long-term use anticoagul,Acq absnce cervix/uterus,Status-post ptca,Abn react-artif implant
Admission Date:  [**2108-11-28**]              Discharge Date:   [**2108-12-4**]

Date of Birth:  [**2047-2-3**]             Sex:   F

Service: MEDICINE

Allergies:
Ambien / Percocet / Iodine; Iodine Containing

Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2108-11-29**] x 2


History of Present Illness:
61yo F w/ hx of HTN, hyperlipidemia, DM, CAD, s/p MI and CABG x
3 (LIMA-LAD, SVG-OM, SVG-RCA) in [**2097**], s/p known occluded vein
grafts, s/p cardiac cath in [**2103**] c/b dissection of the LCx and
s/p 2
Cypher DES placed. Pt is s/p prosthetic [**Year (4 digits) 1291**] in [**1-/2107**] for AS and
underwent cath prior to that surgery and had a BMS to the left
subclavian artery.  Most recently [**2108-10-1**] had 80% ostial LAD
lesions and got BMS to proximal LAD.
.
Patient reports worsening chest pain over the last few months,
and reports using nitro multiple times a day.  This pain occurs
with rest and with activity.  She describes intermittent chest
pain over past 3 days which became constant, associated with
diaphoresis.  On the day of presentation, the patient had sudden
onset of substernal chest pain while walking, and experienced
associated shortness of breath, palpitations, diaphoresis.  She
denies any presyncopal symptoms, nausea, or vomiting.  Despite
[**3-31**] does of NTG, the pain was did not improve, and the patient
activated EMS.
.
When EMS arrived in the field, HR was 210, BP 160/110.  Pt was
given SL NTG and Lopressor 5mg IV X 3 which brought rate to
140s-150s.  On presentation to ED, initial vitals were BP
144/106, HR 85, RR 20, 98% on 2L.  Pt received several mg IV
morphine, nitro 0.4mg LS, ativan 0.5mg IV, then 1mg IV, dilauded
1mg X 2, ASA 325, Lopressor 5mg IV X 2.  Was started on Nitro
gtt which was increased to 200mcg/min. Despite these
medications, the patient only had mild improvement of symptoms.
Initial ECG showed afib with new LBBB pattern, ST depressions in
V5, V6.  Given unremitting chest pain and positive cardiac
markers, the patient was admitted to the CCU for further
monitoring with planned cath in the morning.

Past Medical History:
1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cath [**2108-10-1**]:
R-dominant 3 vessel native disease.
LMCA with dual ostia
Ostial LAD had an 80% stenosis with poor perfusion of D1 and s1,
got BMS to proximal LAD
Stenosis in the LAD distal to the takeoff of D1 that impairs
flow from D1 to the LAD
LCX has a aproximal 40% stenosis
SVGs were known to be occluded
selective conduit arteriography revealed a patent LIMA to LAD
The subclavian artery had a 30% in stent restenosis

3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Osteoarthritis
Rheumatoid arthritis
Lap cholecystectomy on [**2108-7-9**]
Iron deficiency anemia
S/P appendectomy
S/P total abdominal hysterectomy
Depression
Fibromyalgia
Post-op Atrial Fibrillation
Aortic Stenosis/ASD s/p Redo-Sternotomy
s/p Aortic Valve Replacement
ASD closure


Social History:
No tobacco or alcohol use.  Lives alone, has 3 children.

Family History:
Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

Physical Exam:
VS: T99.8 BP 136/57 HR 106 O2 98% on 2L
GENERAL: WDWN female crying, anxious, but appears comfortable
Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No dentition.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly, irregular rhytyth, tachycardic, normal S1,
S2. [**2-1**] low pitched murmur heard best LLSB and apex.  [**1-1**] slight
higher pitched murmur at LUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
[**2108-11-28**] 08:00PM BLOOD WBC-8.5# RBC-4.21 Hgb-10.0* Hct-30.6*
MCV-73* MCH-23.7* MCHC-32.5 RDW-13.7 Plt Ct-380#
[**2108-11-28**] 08:00PM BLOOD Neuts-67.7 Lymphs-25.5 Monos-4.6 Eos-1.5
Baso-0.6
[**2108-11-28**] 08:00PM BLOOD PT-30.2* PTT-33.6 INR(PT)-3.1*
[**2108-11-28**] 08:00PM BLOOD Glucose-190* UreaN-12 Creat-0.9 Na-138
K-3.9 Cl-105 HCO3-24 AnGap-13
[**2108-11-28**] 08:00PM BLOOD CK-MB-5 cTropnT-0.40*
[**2108-11-29**] 12:35AM BLOOD cTropnT-0.81*
[**2108-11-29**] 06:21AM BLOOD CK-MB-70* MB Indx-8.3* cTropnT-1.97*
[**2108-11-29**] 12:23PM BLOOD CK-MB-39* MB Indx-6.3* cTropnT-1.32*
[**2108-12-3**] 07:05AM BLOOD calTIBC-372 Ferritn-21 TRF-286
[**2108-11-29**] 06:21AM BLOOD Hapto-47
[**2108-11-29**] 06:21AM BLOOD %HbA1c-6.3*
[**2108-11-29**] 06:21AM BLOOD Triglyc-83 HDL-51 CHOL/HD-3.9 LDLcalc-129
.
EKG [**2108-11-28**] on arrival to the CCU: AF at 90, new LBBb since
[**18**]:51, ST depresions V5 + V6 1mm (new,) old ST demp and TW I in
I + aVL (slighly worsened)
.
CXR [**2108-11-28**]: Cardiomegaly with mild congestion, possible small
right pleural effusion.
.
Cardiac Cath [**2108-11-29**]:
1. Three vessel coronary artery disease.
2. In stent restenosis of proximal LAD bare metal stent.
3. Patent LIMA to LAD.
.
Cardiac Cath [**2108-11-29**] #2:
1. Three vessel coronary artery disease.
2. Successful stenting of the proximal LAD (ISRS) with a Xience
DES.
3. Successful POBA pf the LAD into the diagonal branch distal to
the
stent.
4. Severe proximal external iliac stenosis.
5. The patient was pre-treated for her reported contrast
allergy.
.
ECG [**2108-11-30**] (with chest pain): Junctional rhythm with A-V
dissociation at an atrial rate of about 38 and a ventricular
rate of 82. Right bundle-branch block. Left anterior fascicular
block. Probable left ventricular hypertrophy. Lateral ST-T wave
changes  could be due to left ventricular hypertrophy and/or
ischemia. Prolonged Q-T interval. Compared to the previous
tracing of [**2108-11-29**] right bundle-branch block and left anterior
fascicular block are new. Lateral ST segment depression is
present. A-V dissociation is also present.
.
Stress Test [**2108-12-3**]: Questionable anginal symptoms with no
additional ECG
changes noted from baseline. Nuclear report sent separately.
.
Persatine Mibi [**2108-12-3**]: 1. Improvement of the previously
described fixed inferior wall perfusion defect. No definite new
or reversible perfusion defects identified, although the
myocardium appears heterogeneous. 2. Global hypokinesis with an
LVEF of 36%.


Brief Hospital Course:
1. NON-ST ELEVATION MI
The patient presented with chest pain, ST depressions on ECG and
positive biomarkers consistent with an NSTEMI.  She was
initially placed on a nitro drip in the ED and given Morphine,
then Dilaudid for pain control.  Upon arrival to the CCU on
[**2108-11-29**], she underwent cardiac catheterization during which an
in-stent restenosis of her BMS to LAD was seen.  She had distal
filling via her LIMA graft and no intervention was performed.
The patient continued to have chest pain post-procedure and was
taken back to the cath lab later that day.  She had a DES placed
in the in-stent thrombosis of her prior BMS to LAD.  She was
able to be weaned off the nitro drip and chest pain subsided.
She was transferred out of the CCU on [**2108-11-30**].  She continued to
take her home doses of MS Contin and Morphine IR for pain
control.  She was chest pain free until the morning of [**2108-12-2**]
when she developed an episode of chest pain similar to her
anginal pain while walking to the bathroom.  ECG showed a
junctional rhythm with RBBB which had changed from admission.
Pain was releived with rest and SL nitro X 1.  The patient then
developed chest pain later that same day of similar nature.  Her
isosorbide mononitrate was increased first to 60mg PO qday, then
to 90mg PO qday.  Her metoprolol was decreased due to the
junctional rhythm.  She underwent a persantine mibi study on
[**2108-12-3**] during which she had some questionable anginal symptoms
but imaging did not show any reversible ischemia.  She walked
with PT and was chest pain free.  She was discharged on [**2108-12-4**]
on aspirin, plavix, metoprolol, lipitor and imdur.
.
2. COUGH, FEVER
The patient spiked a temperature on [**2108-11-30**] and had a cough.
She was started emperically on Levofloxacin for possible
pneumonia.  She was not hypoxic and CXR was without infiltrate.
She completed a 5 day course of Levofloxacin for possible
atypical pneumonia.
.
3. JUNCTIONAL RHYTHM
In the ED, the patient was tachycardic with HR in the 130.  It
was unclear if this was atrial fibrillation.  She was initially
control on her home dose of Toprol XL 100mg PO qday.  Later in
her hospital course, the patient developed a junctional rhythm
with her chest pain with a HR in the 60s.  Her metoprolol dose
was decreased to 50mg PO TID due to this rhythm.  She remained
otherwise asymptomatic.
.
4. HYPERTENSION
Ms. [**Known lastname 13469**] was hypertensive at presentation and started on a
nitroglycerin drip.  She was able to be weaned off this drip and
started on her home medications to control her blood pressure.
She continued on Lisinopril and Metoprolol, and Amlodipine was
added to her medication regimen.
.
5. HX OF AORTIC VALVE REPLACEMENT
The patient was therapeutic on her coumadin upon arrival.  Due
to interation with levofloxacin, she was supratherapeutic at 4.3
on [**2108-12-2**] and her coumadin dose was held this day.  She was
restarted at a lower dose on [**2108-12-3**] for an INR of 3.3.  On
discharge, her INR was 2.3 and she was told to take her home
dose of Coumadin 7.5mg PO qday.  She was instructed to have her
INR checked in 3 days.  She completed the Levofloxacin on
[**2108-12-4**].
.
6. DEPRESSION:
She was continued on Duloxetine for depression.
.
7. HYPOTHYROIDISM
Ms. [**Known lastname 13469**] was continued on Levothyroxine for her hypothyroidism.
.
On discharge, Ms. [**Known lastname 13469**] was given follow-up appointments with
her cardiologist and primary care doctor.  She was instructed to
decrease her Metoprolol to 50mg PO TID.  Her Crestor was changed
to Lipitor 80mg PO qday.  She was started on Amlodipine 5mg PO
qday.  Her Imdur was increased to 90mg PO qday.  Her lasix was
stopped.

Medications on Admission:
Lasix 20mg PO qday
Omeprazole 20mg PO qday
Rosuvastatin 20mg PO qday
Levothyroxine 50mcg PO qday
Imdur 120mg PO qday
Duloxetine 60mg PO qday
Colace 100mg PO BID
Ferrous Sulfate 325mg PO qday
Maalox 30ml PO q12hours PRN
Morphine 15mg PO q12 hours
Trazodone 150-200mg PO qHS PRN insomnia
Ascorbic Acid 1000mg PO qday
Clopidogrel 75mg PO qday
Morphine 30mg PO q4 hours PRN X 10 days
Lisinopril 80mg PO qday
NTG 0.4mg SL 1-2 tabs q6hours PRN
Toprol XL 300mg PO qday
Warfarin 7.5 g PO qday
Acetaminophen 325 - 650mg PO q6H PRN


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
4. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
5. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Known lastname **]:*30 Tablet(s)* Refills:*2*
7. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO once a
day.
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
[**Known lastname **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Outpatient Lab Work
Please check INR on Wednesday [**12-5**] and call results to
Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 22972**]
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) ml PO
once a day as needed for constipation.
13. Trazodone 100 mg Tablet Sig: 1-3 Tablets PO at bedtime as
needed for insomnia.
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Nitrostat 0.4 mg Tablet, Sublingual Sig: 1-2 tabs Sublingual
q 5 minutes x3.
16. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
17. Imdur 30 mg Tablet Sustained Release 24 hr Sig: Three (3)
Tablet Sustained Release 24 hr PO once a day.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
[**Telephone/Fax (1) **]:*90 Tablet(s)* Refills:*2*
19. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for headache.
21. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
22. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ml PO Q6H (every 6 hours) as needed for constipation.
[**Telephone/Fax (1) **]:*2 bottles* Refills:*1*
23. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
24. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
1. ST Elevation MI
2. Congestive Heart Failure
3. Community Acquired Pneumonia

Secondary Diagnoses:
4. s/p Aortic Valve Replacement
5. Hypothyroidism
6. Coronary Artery Disease
7. Hypertension
8. Hyperlipidemia


Discharge Condition:
Hemodynamically stable without chest pain


Discharge Instructions:
You had a heart attack and a cardiac catheterization with a drug
eluting stent to your left artery. You also had some fluid
retention because your heart was weak, this was treated with
furosemide and we adjusted your medicines. Your atrial
fibrillation rate was fast and was treated with metoprolol.
Finally, you underwent a cardiac stress test that did not show
any new defects in your heart and no areas that could be
improved by intervention.

Please weight yourself every day.  If your weight increases >
3lbs, please call your cardiologist.  Please adhere to low salt,
heart healthy diet.

Medication changes:
1. Your Imdur was decreased to 90 mg
2. Your Omeprazole was increased to 40 mg daily
3. You were started on Norvasc to control your blood pressure.
4. Stop taking your Lasix
5. Please take 7.5 mg or Warfarin over the weekend.
6. You were found to be iron deficient and should take 325 mg of
ferrous sulfate daily, however this may interact with your
thyroid [**Last Name (LF) 87044**], [**First Name3 (LF) **] please discuss this with your primary
doctor first.
7. Your Metoprolol was changed to 50mg three times daily.
8. You were started on Lipitor 80mg daily, your crestor was
discontinued.
.
Please have your INR checked on Wednesday [**12-5**] and call
results to Dr.[**Name (NI) 9388**] office, ([**Telephone/Fax (1) 22972**].
.
Please call Dr. [**Last Name (STitle) **] if you have any further chest pain,
trouble breathing, unusual fatigue, dark or tarry
stools,palpitations, dizziness or any other concerning symptoms.


Followup Instructions:
Please have your INR checked on Wednesday [**12-5**] and call
results to Dr.[**Name (NI) 9388**] office, ([**Telephone/Fax (1) 22972**].

Primary Care:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone [**Telephone/Fax (1) 17753**]  Date/time Friday [**12-7**] at
11:15am.

Cardiology
[**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD [**Last Name (Titles) 105861**] [**Telephone/Fax (1) 4105**] Date/time: Wednesday,
[**12-19**] at 11:15am.
{'Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other left bundle branch block,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Atherosclerosis of other specified arteries,Depressive disorder, not elsewhere classified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Atrial fibrillation,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Insomnia, unspecified,Old myocardial infarction,Heart valve replaced by other means,Other acquired absence of organ,Long-term (current) use of anticoagulants,Acquired absence of both cervix and uterus,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: 61yo F w/ hx of HTN, hyperlipidemia, DM, CAD, s/p MI and CABG x
3 (LIMA-LAD, SVG-OM, SVG-RCA) in [**2097**], s/p known occluded vein
grafts, s/p cardiac cath in [**2103**] c/b dissection of the LCx and
s/p 2
Cypher DES placed. Pt is s/p prosthetic [**Year (4 digits) 1291**] in [**1-/2107**] for AS and
underwent cath prior to that surgery and had a BMS to the left
subclavian artery.  Most recently [**2108-10-1**] had 80% ostial LAD
lesions and got BMS to proximal LAD.
.
Patient reports worsening chest pain over the last few months,
and reports using nitro multiple times a day.  This pain occurs
with rest and with activity.  She describes intermittent chest
pain over past 3 days which became constant, associated with
diaphoresis.  On the day of presentation, the patient had sudden
onset of substernal chest pain while walking, and experienced
associated shortness of breath, palpitations, diaphoresis.  She
denies any presyncopal symptoms, nausea, or vomiting.  Despite
[**3-31**] does of NTG, the pain was did not improve, and the patient
activated EMS.
.
When EMS arrived in the field, HR was 210, BP 160/110.  Pt was
given SL NTG and Lopressor 5mg IV X 3 which brought rate to
140s-150s.  On presentation to ED, initial vitals were BP
144/106, HR 85, RR 20, 98% on 2L.  Pt received several mg IV
morphine, nitro 0.4mg LS, ativan 0.5mg IV, then 1mg IV, dilauded
1mg X 2, ASA 325, Lopressor 5mg IV X 2.  Was started on Nitro
gtt which was increased to 200mcg/min. Despite these
medications, the patient only had mild improvement of symptoms.
Initial ECG showed afib with new LBBB pattern, ST depressions in
V5, V6.  Given unremitting chest pain and positive cardiac
markers, the patient was admitted to the CCU for further
monitoring with planned cath in the morning.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS:: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
Cath [**2108-10-1**]:
R-dominant 3 vessel native disease.
LMCA with dual ostia
Ostial LAD had an 80% stenosis with poor perfusion of D1 and s1,
got BMS to proximal LAD
Stenosis in the LAD distal to the takeoff of D1 that impairs
flow from D1 to the LAD
LCX has a aproximal 40% stenosis
SVGs were known to be occluded
selective conduit arteriography revealed a patent LIMA to LAD
The subclavian artery had a 30% in stent restenosis

MEDICATION ON ADMISSION: Lasix 20mg PO qday
Omeprazole 20mg PO qday
Rosuvastatin 20mg PO qday
Levothyroxine 50mcg PO qday
Imdur 120mg PO qday
Duloxetine 60mg PO qday
Colace 100mg PO BID
Ferrous Sulfate 325mg PO qday
Maalox 30ml PO q12hours PRN
Morphine 15mg PO q12 hours
Trazodone 150-200mg PO qHS PRN insomnia
Ascorbic Acid 1000mg PO qday
Clopidogrel 75mg PO qday
Morphine 30mg PO q4 hours PRN X 10 days
Lisinopril 80mg PO qday
NTG 0.4mg SL 1-2 tabs q6hours PRN
Toprol XL 300mg PO qday
Warfarin 7.5 g PO qday
Acetaminophen 325 - 650mg PO q6H PRN

ALLERGIES: Ambien / Percocet / Iodine; Iodine Containing

PHYSICAL EXAM: VS: T99.8 BP 136/57 HR 106 O2 98% on 2L
GENERAL: WDWN female crying, anxious, but appears comfortable
Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No dentition.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly, irregular rhytyth, tachycardic, normal S1,
S2. [**2-1**] low pitched murmur heard best LLSB and apex.  [**1-1**] slight
higher pitched murmur at LUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Slight crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: Mother with CABG at age 48, died of CAD at age 68. Father had
diabetes and coronary artery disease and died of an MI vs.
prostate cancer.

SOCIAL HISTORY: No tobacco or alcohol use.  Lives alone, has 3 children. 

### Response:
{'Other complications due to other cardiac device, implant, and graft,Subendocardial infarction, initial episode of care,Coronary atherosclerosis of autologous vein bypass graft,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Other left bundle branch block,Iron deficiency anemia, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis,Atherosclerosis of other specified arteries,Depressive disorder, not elsewhere classified,Myalgia and myositis, unspecified,Unspecified acquired hypothyroidism,Atrial fibrillation,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Insomnia, unspecified,Old myocardial infarction,Heart valve replaced by other means,Other acquired absence of organ,Long-term (current) use of anticoagulants,Acquired absence of both cervix and uterus,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
