CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 86 year old male w/ pacer, svt, avnrt, mvr, htn, high chol,
panhypopit with chief complaint of chest pain. No prior CAD, now
intubated with ST depressions anteroseptally and elevations
inferiorly in setting of AV paced rhythm. In field BP 60/P but
mentating. Went directly to Cath lab where he had 40 % LMCA
ulcerated lesion, 99% prox. Lcx occlusion with thrombus and 80%
mid LAD. He was left dominant. Patient had Kissing DES to LCX,
LAD into LMCA ostium. His PCWP on 2 pressors and IABP was 22
mmHg. CO 5.18 l/min and CI 2.80 l/min. He had episode of VT on
Dopamine in lab requiring shock. Sent up to CCU on small dose of
Levophed and IABP, intubated.

MEDICAL HISTORY: 1. HTN
2. Hyperlipid.
3. Pan-Hypopit s/p pituitary adenoma resection [**2158**] on only
Synthroid
4. H/O Tachy-Brady syndrome s/p PPM in [**2154**]
5. H/O SVT
5. h/o SIADH

MEDICATION ON ADMISSION: Prednisone 5 mg po qd
Lipitor
HCTZ
Avapro
Prevacid
Synthroid
Toprol
Testosterone patch

ALLERGIES: Norvasc

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute myocardial infarction of other lateral wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Primary pulmonary hypertension,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia
AMI lateral NEC, initial,Cardiogenic shock,CHF NOS,Pneumonia, organism NOS,Atrial fibrillation,Prim pulm hypertension,Crnry athrscl natve vssl,Anemia NOS,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2167-1-27**]              Discharge Date:   [**2167-2-12**]


Service: MEDICINE

Allergies:
Norvasc

Attending:[**First Name3 (LF) 317**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
cardiac catheterization and stent placement

History of Present Illness:
86 year old male w/ pacer, svt, avnrt, mvr, htn, high chol,
panhypopit with chief complaint of chest pain. No prior CAD, now
intubated with ST depressions anteroseptally and elevations
inferiorly in setting of AV paced rhythm. In field BP 60/P but
mentating. Went directly to Cath lab where he had 40 % LMCA
ulcerated lesion, 99% prox. Lcx occlusion with thrombus and 80%
mid LAD. He was left dominant. Patient had Kissing DES to LCX,
LAD into LMCA ostium. His PCWP on 2 pressors and IABP was 22
mmHg. CO 5.18 l/min and CI 2.80 l/min. He had episode of VT on
Dopamine in lab requiring shock. Sent up to CCU on small dose of
Levophed and IABP, intubated.

Past Medical History:
1. HTN
2. Hyperlipid.
3. Pan-Hypopit s/p pituitary adenoma resection [**2158**] on only
Synthroid
4. H/O Tachy-Brady syndrome s/p PPM in [**2154**]
5. H/O SVT
5. h/o SIADH


Pertinent Results:
[**2167-2-8**] 07:45AM BLOOD WBC-14.1* RBC-3.93* Hgb-12.2* Hct-35.5*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.2 Plt Ct-362
[**2167-2-7**] 06:45AM BLOOD WBC-11.3* RBC-4.06* Hgb-12.3* Hct-36.5*
MCV-90 MCH-30.3 MCHC-33.6 RDW-13.5 Plt Ct-371
[**2167-2-1**] 06:00AM BLOOD WBC-7.4 RBC-3.27* Hgb-10.3* Hct-28.9*
MCV-89 MCH-31.4 MCHC-35.6* RDW-14.4 Plt Ct-132*
[**2167-1-30**] 04:34PM BLOOD Hct-25.9*
[**2167-2-8**] 07:45AM BLOOD Glucose-86 UreaN-31* Creat-0.9 Na-141
K-3.7 Cl-105 HCO3-31* AnGap-9
[**2167-1-29**] 04:53AM BLOOD CK(CPK)-1850*
[**2167-1-28**] 05:14PM BLOOD CK(CPK)-2785*
[**2167-1-28**] 03:59AM BLOOD CK(CPK)-3764*
[**2167-1-27**] 10:55PM BLOOD CK(CPK)-4056*
[**2167-1-29**] 04:53AM BLOOD CK-MB-57* MB Indx-3.1 cTropnT-6.17*
[**2167-1-28**] 05:14PM BLOOD CK-MB-99* MB Indx-3.6 cTropnT-7.96*
[**2167-1-28**] 03:59AM BLOOD CK-MB-253* MB Indx-6.7* cTropnT-12.68*
[**2167-1-27**] 11:45AM BLOOD cTropnT-0.02*
[**2167-1-28**] 08:25AM BLOOD Hapto-20*
[**2167-2-7**] 06:45AM BLOOD TSH-1.9
[**2167-2-7**] 06:45AM BLOOD Free T4-1.3
[**2167-1-28**] 05:14PM BLOOD Cortsol-216.4*

CT scan: There is a small amount of retroperitoneal hemorrhage
present, as well as bleeding into the left psoas and right
iliacus muscle. There is no dominant retroperitoneal hemorrhage
collection.

TTE [**2167-1-28**]: Conclusions:  The left ventricular cavity is
unusually small. There is mild regional left ventricular
systolic dysfunction. LV systolic function appears depressed.
Right ventricular chamber size is normal. The aortic valve
leaflets are mildly thickened. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
Compared with the prior study (tape reviewed) of [**2167-1-27**], left
ventricular systolic function appears similar to slightly
improved except that the heart rate is now higher.

TTE [**2167-1-27**]: Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Marked lateral
hypokinesis and
inferior/posteror akinesis are present.
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic
function appears depressed.
4. The ascending aorta is mildly dilated.
5. Trace aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.

Cardiac Cath:
HEMODYNAMICS RESULTS BODY SURFACE AREA:  1.85 m2
  HEMOGLOBIN: 13.4 gms %
  FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 26/27/23 16/17/14
RIGHT VENTRICLE {s/ed} 47/26 36/16
PULMONARY ARTERY {s/d/m} 47/27/33 36/22/28
PULMONARY WEDGE {a/v/m} 31/42/29 24/27/22
AORTA {s/d/m} 80/104/*
**CARDIAC OUTPUT
HEART RATE {beats/min} 80
RHYTHM PACED
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 45
CARD. OP/IND FICK {l/mn/m2} 5.1/2.8
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 926
PULMONARY VASC. RESISTANCE 63

**% SATURATION DATA (NL)
PA MAIN 74

COMMENTS:
1. Selective coronary angiography revealed a left dominant
system. The
LCX had a 99% proximal stenosis with thrombus. The LMCA had an
ulcerated
plaque with a 40% stenosis. The LAD had an 80% mid-vessel
lesion. The
RCA was small and nondominant.
2. Hemodynamics on entry showed elevated filling pressures
(RVEDP 26 mm
Hg, PCWP mean 29 mm Hg), moderate pulmonary hypertension (PASP
47 mm
Hg), and a normal cardiac index (2.8 l/mn/m2) while on dopamine,

levophed, and with the IABP in place on 1:1. Additionally, there
were
large V waves to 42 mm Hg in the PCWP tracing, suggestive of
ischemic
mitral regurgitation.
3. Hemodynamics after intervention showed decreased filling
pressures
(RVEDP 16 mm Hg, PCWP mean 22 mm Hg) without the large V waves
on the
PCWP tracing. Post intervention the pulmonary hypertension was
less
severe (PASP 36 mm Hg).
4. Diagnostic procedure was complicated by one episode of
ventricular
tachycardia, which resolved with 200 J defibrillation and
lidocaine 100
mg IV bolus.
5. Successful primary PCI of the LCX with a 3.0 x 18 mm Cypher
DES,
complicated by likely stent thrombosis, treated with a 3.5 mm
balloon
and export cathter.
6. Successful PCI of the proximal-mid LAD with a 3.0 x 18 mm
Cypher DES.
7. Successful kissing stent deployment in the LMCA into the LAD
(3.0 x
23 mm) and LCX (3.5 x 23 mm) with two Cypher DES.

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Ischemic MR.
3. Moderate pulmonary hypertension. Elevated filling pressures.
4. Acute lateral myocardial infarction, managed by acute PCI of
the
LCX, LAD, and LMCA.
5. Cardiogenic shock, managed with IABP insertion.



Brief Hospital Course:
1. CAD:  Mr. [**Known lastname 5448**] was taken emergently to the cath lab, and
had stents to his LCx, LAD, and kissing stents placed in his
LMCA.  An IABP was placed in the lab, and he was transferred to
the CCU on levophed.  One day after admission, his BP acutely
dropped and a stat echo was obtained.  This was essentially
unchanged from one day prior.  His balloon pump and levophed
were eventually weaned off.  He was kept on aspirin, plavix, and
a statin.  He was placed on an ACE inhibitor and a beta blocker,
which were titrated up for pulse and blood pressure control.  He
will need to have a relook cath in 3 months given his L main
stents.

2. Pump:  His EF was 30%, and he received a great deal of IVF
resuscitation.  Once his bp stabilized, he was aggressively
diuresed with Lasix.  He had a repeat echo the day after
admission which demonstrated an improved EF, of 40-45%.  He was
placed on [**First Name8 (NamePattern2) **] [**Last Name (un) **] for afterload reduction, and a beta blocker was
added later.

3. Rhythm:  He had a pacemaker already in place, and initially
he was intermittently A-sensing and V-pacing, as well as AV
pacing.  This was changed by the attending so that he was
a-sensing and a-pacing.  He also had a very short (minutes) run
of afib, which self-terminated.  He was bolused with amio and
placed on an amio drip, and then changed to po loading doses.
This was tapered down to 400 mg po daily.  Per the attending,
because he had peri-MI afib, he may only need 1 month of
amiodarone and then this can stop altogether.  He had no further
arrhythmias.  He was not anticoagulated [**1-14**] GI bleed.

4. Pulm: He was initially intubated because he was hypotensive
and unstable.  He remained intubated in the setting of his
volume overload, and he wasn't extubated until his pulmonary
status was maximized with diuresis.  He also had thick
secretions from his ET tube, which twice grew out serratia.  He
had an infiltrate on CXR.  He was treated initially with Zosyn,
which was changed to levofloxacin per sensitivities, for a total
10 day course.

5. Endocrine:  Because of his history of pan-hypo pit and his
hypotension, he was placed on stress-dose steroids.  These were
tapered down once his bp was stable, and need to be tapered to
his home dose of prednisone 5 mg po qd. Please see discharge
instructions. He was placed on an insulin sliding scale while on
the high dose steroids, as well as synthroid. He no longer
required the insulin once his steriods were tapered.

6. Altered mental status:  He remained slightly confused with a
labile mood, even after transfer out to the floor.  He was seen
by psychiatry, who recommended Haldol 0.5 mg po qhs.  However,
after this he developed bilateral intention tremor of his hands,
and the haldol was discontinued.

7. Anemia:  His hematocrit initially dropped, but this was felt
dilutional [**1-14**] his large volume resuscitation.  However, his
crit dropped sharply on [**1-30**], and he had a CT scan
which showed a small retroperitoneal bleed with psoas and
iliacus muscle bleeds.  His heparin (for the afib) was stopped,
and he was transfused to a crit over 30.  He remained
hemodynamically stable, and his hematocrit was stable after
this.  He did have guaiac positive stool, but no gross melena or
bright red blood per rectum.

Medications on Admission:
Prednisone 5 mg po qd
Lipitor
HCTZ
Avapro
Prevacid
Synthroid
Toprol
Testosterone patch

Discharge Medications:
1. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Milk of Magnesia 311 mg Tablet, Chewable Sig: One (1) ML PO
Q6H (every 6 hours) as needed for heartburn.
9. Atacand 4 mg Tablet Sig: One (1) Tablet PO QD ().
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
12. Amiodarone HCl 200 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily) for 9 days: then start 200 mg per day for 3 more weeks,
then off.
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: [**12-14**] Tablet Sustained Release 24HR PO DAILY (Daily): hold
for sbp < 100, hr < 60.
14. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: Then 10 mg for 7 days then 5 mg ongoing.
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Three (3) Capsule, Sustained Release PO DAILY (Daily).
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for systolic blood pressure < 100.
17. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
1. s/p acute MI, cardiogenic shock
2. Hyperlipidemia
3. Pan-Hypopituitary s/p pituitary adenoma resection [**2158**] on
only Synthroid
4. History of Tachy-Brady syndrome s/p PPM in [**2154**]
5. H/O SVT
5. h/o SIADH
6. Hypertension
7. CHF

Discharge Condition:
good

Discharge Instructions:
Continue amiodarone, aspirin, lipitor, captopril, plavix,
lisinopril, toprol, lasix, prednisone, aldactone, synthroid and
also complete a course of levaquin.

Call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chest pain, shortness of breath,
dizzyness, or swollen legs.

You will also need to complete a steroid taper. Please see
attached prescription.

Followup Instructions:
You should have another cardiac catheterization in 3 months.

Please see your PCP [**Last Name (NamePattern4) **] 2 weeks: [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 1713**]

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2167-2-24**] 2:15

Please draw a chemistry and complete blood count in 5 days. Have
your blood pressure checked and adjust lasix, atacand, and
metoprolol accordingly.
{'Acute myocardial infarction of other lateral wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Primary pulmonary hypertension,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: 86 year old male w/ pacer, svt, avnrt, mvr, htn, high chol,
panhypopit with chief complaint of chest pain. No prior CAD, now
intubated with ST depressions anteroseptally and elevations
inferiorly in setting of AV paced rhythm. In field BP 60/P but
mentating. Went directly to Cath lab where he had 40 % LMCA
ulcerated lesion, 99% prox. Lcx occlusion with thrombus and 80%
mid LAD. He was left dominant. Patient had Kissing DES to LCX,
LAD into LMCA ostium. His PCWP on 2 pressors and IABP was 22
mmHg. CO 5.18 l/min and CI 2.80 l/min. He had episode of VT on
Dopamine in lab requiring shock. Sent up to CCU on small dose of
Levophed and IABP, intubated.

MEDICAL HISTORY: 1. HTN
2. Hyperlipid.
3. Pan-Hypopit s/p pituitary adenoma resection [**2158**] on only
Synthroid
4. H/O Tachy-Brady syndrome s/p PPM in [**2154**]
5. H/O SVT
5. h/o SIADH

MEDICATION ON ADMISSION: Prednisone 5 mg po qd
Lipitor
HCTZ
Avapro
Prevacid
Synthroid
Toprol
Testosterone patch

ALLERGIES: Norvasc

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute myocardial infarction of other lateral wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Pneumonia, organism unspecified,Atrial fibrillation,Primary pulmonary hypertension,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia'}
