CHIEF COMPLAINT: NSTEMI/DIC

PRESENT ILLNESS: The patient is an 84 yo Male w/PMH of CAD s/p CABGx3 on [**2162-3-12**]
at [**Hospital1 **] Center, CKD, HTN who presented initially to the
[**Hospital1 **] center on [**2162-3-27**] with several days of fatigue and
decreased appetite. On admission to [**Hospital1 **] Center BUN/CR
80/3.9; PLT 35, H/H 9.4/28.5. There was originally concern for
obstruction, a foley was placed with 500 cc UO. UA was notable
for trace protein, ketones, bacteria, [**2-10**] wbc, [**4-12**] rbc. Renal US
was negative for lesions or hydronephrosis. He was started on
D5NS at 75 cc/hour and given one dose of albumin 250 cc. A TTE
was done with EF 40-45%. His K was noted to be 6.0 so Kayexylate
was given. He was given 500 mg diuril prior to transfer to the
[**Hospital1 18**] [**Hospital Unit Name 153**].
.
The patient's MICU course was complicated by thrombocytopenia
with elevated FDP/D-dimer thought likely to represent DIC,
troponin elevation with ? NSTEMI, renal failure, and possible
saphenous vein donor site infection.
.

MEDICAL HISTORY: Past Medical History:
HTN
CAD s/p CABG x 3
- LIMA to LAD, RSVG to PLV/OM1) on [**2162-3-12**]
- Post-op complicated by atrial fibrillation treated with
amiodarone
Hyperlipidemia
CKD - baseline 1.3-1.7
Prostate Ca - s/p xrt
GERD
Pulmonary nodule - stable x 2 years
.
PSH:
1)CABG as above
2)S/P R CEA [**2151**]
3)S/P CCY
4)S/P L TKR
5)S/P Hernia repair

MEDICATION ON ADMISSION: aspirin 81 mg daily
amiodarone 200 mg daily
pepcid 20 mg daily
colace 100 mg [**Hospital1 **]
lopressor 12.5 mg [**Hospital1 **]
lovastatin 40 mg daily
tylenol #3 prn

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Vitals: T- 95.5 BP: 122/50 HR: 58 RR: 22 O2: 98% on 2L
.
General: Patient is an elderly male, appears tired but in NAD,
very pleasant
HEENT: NCAT, EOMI. + right neck well healed scar s/p previous
CEA.
Neck: EJ distended. JVP appprox 10cm
Chest: Few scattered high pitched expiratory wheezes. Mildly
decreased BS at left base but otherwise CTA. No rales
appreciated. Healing sternotomy scar with dressing below
sternotomy C/D/I. Non-tender
Cor: RRR, normal S1/S2. No M/R/G appreciated
Abdomen: Soft, non-tender, ND. +BS
Extremity: right LE with significant area of erythmea over
medial aspect of leg, warm. Non-tender, no area of fluctuance
appreciated. + ecchymosis over right foot. 2+ pedal edema
bilaterally. DP 1+ bilaterally, feet warm.

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient is married and lives with his wife. [**Name (NI) **] has 2 sons.
[**Name (NI) **] is a WWII veteran. He lives in [**Location **] RI with his wife
currently, retired meat cutter
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Defibrination syndrome,Atrial fibrillation,Other postoperative infection,Cellulitis and abscess of leg, except foot,Chronic kidney disease, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status
Subendo infarct, initial,Acute kidney failure NOS,Defibrination syndrome,Atrial fibrillation,Other postop infection,Cellulitis of leg,Chronic kidney dis NOS,Esophageal reflux,Hx-prostatic malignancy,Hyperlipidemia NEC/NOS,Hy kid NOS w cr kid I-IV,Aortocoronary bypass
Admission Date:  [**2162-3-27**]              Discharge Date:   [**2162-4-8**]


Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
NSTEMI/DIC

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is an 84 yo Male w/PMH of CAD s/p CABGx3 on [**2162-3-12**]
at [**Hospital1 **] Center, CKD, HTN who presented initially to the
[**Hospital1 **] center on [**2162-3-27**] with several days of fatigue and
decreased appetite. On admission to [**Hospital1 **] Center BUN/CR
80/3.9; PLT 35, H/H 9.4/28.5. There was originally concern for
obstruction, a foley was placed with 500 cc UO. UA was notable
for trace protein, ketones, bacteria, [**2-10**] wbc, [**4-12**] rbc. Renal US
was negative for lesions or hydronephrosis. He was started on
D5NS at 75 cc/hour and given one dose of albumin 250 cc. A TTE
was done with EF 40-45%. His K was noted to be 6.0 so Kayexylate
was given. He was given 500 mg diuril prior to transfer to the
[**Hospital1 18**] [**Hospital Unit Name 153**].
.
The patient's MICU course was complicated by thrombocytopenia
with elevated FDP/D-dimer thought likely to represent DIC,
troponin elevation with ? NSTEMI, renal failure, and possible
saphenous vein donor site infection.
.

Past Medical History:
Past Medical History:
HTN
CAD s/p CABG x 3
- LIMA to LAD, RSVG to PLV/OM1) on [**2162-3-12**]
- Post-op complicated by atrial fibrillation treated with
amiodarone
Hyperlipidemia
CKD - baseline 1.3-1.7
Prostate Ca - s/p xrt
GERD
Pulmonary nodule - stable x 2 years
.
PSH:
1)CABG as above
2)S/P R CEA [**2151**]
3)S/P CCY
4)S/P L TKR
5)S/P Hernia repair


Social History:
The patient is married and lives with his wife. [**Name (NI) **] has 2 sons.
[**Name (NI) **] is a WWII veteran. He lives in [**Location **] RI with his wife
currently, retired meat cutter


Family History:
NC

Physical Exam:
Vitals: T- 95.5 BP: 122/50 HR: 58 RR: 22 O2: 98% on 2L
.
General: Patient is an elderly male, appears tired but in NAD,
very pleasant
HEENT: NCAT, EOMI. + right neck well healed scar s/p previous
CEA.
Neck: EJ distended. JVP appprox 10cm
Chest: Few scattered high pitched expiratory wheezes. Mildly
decreased BS at left base but otherwise CTA. No rales
appreciated. Healing sternotomy scar with dressing below
sternotomy C/D/I. Non-tender
Cor: RRR, normal S1/S2. No M/R/G appreciated
Abdomen: Soft, non-tender, ND. +BS
Extremity: right LE with significant area of erythmea over
medial aspect of leg, warm. Non-tender, no area of fluctuance
appreciated. + ecchymosis over right foot. 2+ pedal edema
bilaterally. DP 1+ bilaterally, feet warm.


Pertinent Results:
[**2162-3-27**] 11:23PM BLOOD WBC-8.4 RBC-2.99* Hgb-8.9* Hct-26.0*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.3 Plt Ct-50*
[**2162-4-4**] 10:05AM BLOOD WBC-7.0 RBC-3.49* Hgb-10.5* Hct-30.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-14.7 Plt Ct-149*
[**2162-3-27**] 11:23PM BLOOD Neuts-82.2* Lymphs-6.6* Monos-6.4
Eos-4.6* Baso-0.2
[**2162-3-27**] 11:23PM BLOOD PT-16.0* PTT-35.2* INR(PT)-1.5*
[**2162-3-27**] 11:23PM BLOOD Plt Ct-50*
[**2162-4-4**] 10:05AM BLOOD Plt Ct-149*
[**2162-3-27**] 11:23PM BLOOD Fibrino-65* D-Dimer-6202*
[**2162-3-27**] 11:23PM BLOOD FDP-320-640*
[**2162-4-3**] 12:00PM BLOOD FDP-40-80
[**2162-3-27**] 11:23PM BLOOD Glucose-106* UreaN-75* Creat-3.6* Na-137
K-4.9 Cl-102 HCO3-25 AnGap-15
[**2162-4-4**] 10:05AM BLOOD Glucose-125* UreaN-29* Creat-1.6* Na-133
K-4.7 Cl-98 HCO3-25 AnGap-15
[**2162-3-27**] 11:23PM BLOOD ALT-41* AST-42* LD(LDH)-399* CK(CPK)-173
AlkPhos-139* TotBili-0.7
[**2162-4-4**] 10:05AM BLOOD ALT-28 AST-24 LD(LDH)-427* AlkPhos-120*
TotBili-0.6
[**2162-3-27**] 11:23PM BLOOD CK-MB-22* MB Indx-12.7* cTropnT-1.18*
[**2162-3-30**] 07:00AM BLOOD CK-MB-13* MB Indx-8.8* cTropnT-1.88*
[**2162-3-31**] 06:45AM BLOOD CK-MB-NotDone cTropnT-3.09*
[**2162-4-1**] 07:25AM BLOOD CK-MB-NotDone cTropnT-3.28*
[**2162-3-27**] 11:23PM BLOOD Hapto-85
[**2162-4-1**] 07:25AM BLOOD TSH-3.1
[**2162-3-28**] 01:46PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE
[**2162-3-27**] 11:23PM BLOOD PSA-<0.1
[**2162-3-28**] 01:46PM BLOOD HCV Ab-NEGATIVE
[**2162-3-30**] 10:15AM BLOOD HEPARIN DEPENDENT ANTIBODIES- positive

ECG: [**2162-3-29**]: NSR, 60, nml axis. Incomplete RBBB. No acute ST
changes. non specific TW changes V1-V6.
.
Imaging:
.
[**2162-3-27**]: Portable Chest - IMPRESSION:
1. Cardiomegaly with small left-sided pleural effusion.
2. No signs for focal consolidation or pulmonary edema.
.
[**2162-3-28**]: Right LENI - negative for DVT, no drainable fluid
collection
.
[**2162-3-30**]: Echocardiogram
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%). Normal regional LV systolic
function. No LV mass/thrombus. No resting LVOT gradient. No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with prior cardiac surgery.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Minimally increased gradient c/w minimal
AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Mild thickening of mitral valve chordae. Calcified tips of
papillary muscles. No MS. Trivial MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.] Normal LV inflow pattern for age.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Normal tricuspid valve supporting structures. No TS. Mild to
moderate [[**2-9**]+] TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
PERICARDIUM: No pericardial effusion.
.
[**2162-4-2**] MRA kidney-
FINDINGS:  There is no evidence of thrombosis within either the
right or left renal vein, or within the IVC. Note is also made
of bilateral pleural effusions as well as a fluid- filled
duodenal diverticulum arising from the 3rd portion of the
duodenum. Multiplanar reformatted images reviewed at the time of
interpretation support these findings.  IMPRESSION:  No evidence
of renal vein thrombosis.
.
[**4-4**] B LENI:  No evidence of left lower extremity deep vein
thrombosis.
Thrombosis of the right greater saphenous vein, not reaching to
the
junction with the common femoral vein.
.


Brief Hospital Course:
Patient is a n 84 yo Male with CAD s/p CABG on [**2162-3-12**] with
course complicated by thrombocytopenia/DIC, ARF, and troponin
leak. Issues as follows:
.
#. Thrombocytopenia/HIT - Pt with persistent thrombocytopenia
since immediately post-op, concerning for postbypass
thrombocytopenia vs HIT. HIT AB strongly positive. Low
fibrinogen and elevated coags consistent with DIC per Hematolgy
who followed that patient. Per, Heme, likely combination of HIT
(heparin induced thrombocytopenia) and DIC (Disseminated
Intravascular Clotting) of unclear etiology (may be secondary to
graft site cellulitis). Started on argatroban and coumadin. Once
INR within recommended therapeutic range (4-5 per Heme),
argatroban was discontinued. An INR 4 hours later was X, which
was in therapeutic range for the patient's chronic needs for
afib and HIT. Patient will need to be on coumadin for 3 months
per Heme. prior to discontinuation of coumadin, will need to
have HIT antibodies tested to ensure resolution. If still
positive, will need to continue on coumadin and should have
hematology follow-up. He should avoid all heparin products in
the future.
.
He received cryoprecipitate, 4U FFP, 2U PRBCs and 1U platelets
during his stay in the MICU.
.
#. CAD - Patient had a troponin leak and was followed by
cardiology.  Troponin rose from 1.18 to 3.28 throughout course.
Initially unclear significance in setting of recent CABG and
ARF. However, decision made to treat for NSTEMI for which
patient is on Aspirin and Beta-blocker, held ACEI and Heparin
given acute renal failure and ? HIT. Echo with preserved EF and
no wall motion abnormalities. Plan for medical management for
now, ? cath in future with further improvement in Creatinine.
Patient had post-op Afib, initially on Amiodarone, but that was
discontinued per cardiology since returned to and stayed in
sinus rhythm. A TSH was within normal limits.
Medically managed with ASA, Beta blocker, Statin, although
statin continued at lowered dose given elevated liver function
tests.
.
#. Pump - Echo reveals preserved Ejection Fraction, no Wall
Motion Abnormalities. Clinically patient appeared mildly volume
overloaded with elevated JVD, peripheral edema and complaints of
mild orthopnea. Was gently diuresis with Lasix after renal
function returned to what appears to be the patient's baseline
with minimal improvement in his symptoms. Still with bilateral
pedal edema and may need to be continually diuresis based on
clinic appearance.
.
#. Renal Failure - Initial consideration given to HUS/TTP as
above but less likely now. Followed by nephrology: unclear
etiology although may be consistent with ATN. This may be [**3-12**]
post-op complication although no reported episode of
hypotension, but at risk as on pump. No eos in urine or other
evidence of cholesterol emboli. Creatinine slowly improved and
patient had adequate urine output daily. MRI of kidneys showed
no renal vein thrombosis.
.
#. Hypoxia - initially required 2L and appeared to be appears
mildy volume overloaded as explained above. Was weaned off
oxygen and then maintained saturations of 95-97 on room air. had
no recurrent episodes of hypoxia but did develop some wheezing
and feelings of lung congestion 2 days prior to discharge.
Wheezing and symptoms improved with albuterol/ipratropium nebs.
Placed on standing nebs and eventually transitioned to spiriva
and albuterol inhalers with resolution of symptoms.
.
# LLE edema - new on exam [**4-4**]. Dependent edema vs. heart
failure. Again, very mildly clinically volume overloaded on
exam. Gently diuresed above with with no resollution of LLE
edema. Compression stocking placed on left leg. Had bilateral
lower extremity ultrasounds which were negative for deep vein
thrombosis on the left with postive clot in the right greater
saphenous (graft site for CABG).
.
#. Atrial fibrillation - episode of afib post-op by report but
in sinus throughout this hospital admission. Continued on
betablocker. Avoid amiodarone given thrombocytopenia per
cardiology. Anticoagulation may not be needed long term if
atrial fibrillation was isolated in response to CABG surgery.
This will need to be reassessed on an outpatient basis.
.
#. Cellulitis - patient afebrile throughout admission without
significant leukocytosis, however, right medial knee was
erythematous and appeared infected clinically. Evaluated by
Surgery who drained what they thought was a nonpurulent
hematoma. Patient was initially treated with Zosyn and
vancomycin but coverage was switched to oral ciprofloxacin when
wound cultures returned with pansensitive Serratia. Wound
continued to improve. Wound care per surgery recs: ace wrap to
right lower extremity and wick placement to graft site wound.
.
Patient is being discharge to a rehabilitation center for
physical therapy and continued post-operative care.

Medications on Admission:
aspirin 81 mg daily
amiodarone 200 mg daily
pepcid 20 mg daily
colace 100 mg [**Hospital1 **]
lopressor 12.5 mg [**Hospital1 **]
lovastatin 40 mg daily
tylenol #3 prn


Discharge Disposition:
Extended Care

Facility:
The Holiday

Discharge Diagnosis:
Non ST Elevation Myocardial Ischemic Event
Disseminated Intravascular Coagulation
Heparin Induced Antibiodies
Graft Site Cellulitis


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital with fatigue and poor appetite
and were found to have acute renal (kidney) failure and some
changes in your blood counts (low platetelets and red blood
cells). You also had elevated cardiac enzymes (lab tests that
are markers of heart muscle damage) which may have been related
to your recent heart surgery or to additional heart damage from
being so ill. You were medically treated as if you had new heart
damage and did very well. Your kidney function improved but you
will need to discuss this with your primary care physician.

However, your platelet level continue to drop after given an
anticoagulant medicine called heparin. You were tested and found
to have antibodies in your blood to heparin which was making
your platelet count fall. You were then switched to a different
medicine, argatroban, and are being bridged to coumadin. You
will need to be on coumadin for 3 months and should have blood
work done prior to discontinuation of coumadin to make sure that
those antibodies have resolved. YOU SHOULD AVOID ALL HEPARIN
PRODUCTS IN THE FUTURE.

Your lab tests have been imroving and are now within the normal
range.

You also had an infection of the graft site of the inside of
your right knee which was opened to allow it to drain by the
Surgery service. You were started on an antibiotic,
ciprofloxacin, and should continue that for a full 10 day
course.  You should also continue to keep your right leg in the
ace bandage until seen by your Heart Surgeons at [**Hospital1 **] Center
in follow-up.

You were had some swelling of your lower legs while in the
hospital which may be related to not being very physically
active or to poor heart function. You were given a diuretic to
help get rid of some of the fluid. Discuss the need for future
diuretic therapy with your primary care physician.

You also complained of some shortness of breath during your
admission, which was improved with medications. You are being
discharged with Spiriva and albuterol inhalers. Please take them
as prescribed.

Please take all medications as prescribed.

Contact a physician for fever > 101.5, worsening redness,
swelling, or pus draining from your incision site, chest pain,
palpitations, dificulty breathing, loss of conciousness,
lightheadedness, or any other concerns.

Followup Instructions:
With your primary care physician [**Name Initial (PRE) 176**] 1-2 weeks.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Defibrination syndrome,Atrial fibrillation,Other postoperative infection,Cellulitis and abscess of leg, except foot,Chronic kidney disease, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status'}


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: NSTEMI/DIC

PRESENT ILLNESS: The patient is an 84 yo Male w/PMH of CAD s/p CABGx3 on [**2162-3-12**]
at [**Hospital1 **] Center, CKD, HTN who presented initially to the
[**Hospital1 **] center on [**2162-3-27**] with several days of fatigue and
decreased appetite. On admission to [**Hospital1 **] Center BUN/CR
80/3.9; PLT 35, H/H 9.4/28.5. There was originally concern for
obstruction, a foley was placed with 500 cc UO. UA was notable
for trace protein, ketones, bacteria, [**2-10**] wbc, [**4-12**] rbc. Renal US
was negative for lesions or hydronephrosis. He was started on
D5NS at 75 cc/hour and given one dose of albumin 250 cc. A TTE
was done with EF 40-45%. His K was noted to be 6.0 so Kayexylate
was given. He was given 500 mg diuril prior to transfer to the
[**Hospital1 18**] [**Hospital Unit Name 153**].
.
The patient's MICU course was complicated by thrombocytopenia
with elevated FDP/D-dimer thought likely to represent DIC,
troponin elevation with ? NSTEMI, renal failure, and possible
saphenous vein donor site infection.
.

MEDICAL HISTORY: Past Medical History:
HTN
CAD s/p CABG x 3
- LIMA to LAD, RSVG to PLV/OM1) on [**2162-3-12**]
- Post-op complicated by atrial fibrillation treated with
amiodarone
Hyperlipidemia
CKD - baseline 1.3-1.7
Prostate Ca - s/p xrt
GERD
Pulmonary nodule - stable x 2 years
.
PSH:
1)CABG as above
2)S/P R CEA [**2151**]
3)S/P CCY
4)S/P L TKR
5)S/P Hernia repair

MEDICATION ON ADMISSION: aspirin 81 mg daily
amiodarone 200 mg daily
pepcid 20 mg daily
colace 100 mg [**Hospital1 **]
lopressor 12.5 mg [**Hospital1 **]
lovastatin 40 mg daily
tylenol #3 prn

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Vitals: T- 95.5 BP: 122/50 HR: 58 RR: 22 O2: 98% on 2L
.
General: Patient is an elderly male, appears tired but in NAD,
very pleasant
HEENT: NCAT, EOMI. + right neck well healed scar s/p previous
CEA.
Neck: EJ distended. JVP appprox 10cm
Chest: Few scattered high pitched expiratory wheezes. Mildly
decreased BS at left base but otherwise CTA. No rales
appreciated. Healing sternotomy scar with dressing below
sternotomy C/D/I. Non-tender
Cor: RRR, normal S1/S2. No M/R/G appreciated
Abdomen: Soft, non-tender, ND. +BS
Extremity: right LE with significant area of erythmea over
medial aspect of leg, warm. Non-tender, no area of fluctuance
appreciated. + ecchymosis over right foot. 2+ pedal edema
bilaterally. DP 1+ bilaterally, feet warm.

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient is married and lives with his wife. [**Name (NI) **] has 2 sons.
[**Name (NI) **] is a WWII veteran. He lives in [**Location **] RI with his wife
currently, retired meat cutter 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Defibrination syndrome,Atrial fibrillation,Other postoperative infection,Cellulitis and abscess of leg, except foot,Chronic kidney disease, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Aortocoronary bypass status'}
