CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 39 M w/ CAD s/p MI, s/p multiple PCI p/w CP. Pt started to have
CP when he was walking in a park w/ his wife. It was his
"familiar" CP. It went away by itself but came back again. He
called 911 and went to OSH when he was still having the CP.
There his EKG was normal and his first set of enzymes showed
trop I 0.00 (nl <0.08) at 1817 on [**4-16**] (no CK available). He was
started on IV heparin and IV nitro. He also received IV
morphine. he was CP free by 8 pm. his second set of enzymes
showed trop I 0.486 (nl <0.034) and CK 184 (nl <170)at 0430 on
[**4-17**]. repeat EKG again   showed NSR and no sig ST-T changes from
previous. He was xferred here for further mgmt.
.
In the CCU he denies CP, SOB. The CP did not recur since last
night.
.
On review of systems, he denies any prior history of stroke,
TIA,  pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. he denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: -End-stage renal disease secondary to crescentic IgA
nephropathy, as diagnosed on renal biopsy in [**2161**], on
hemodialysis for approximately five months before receiving a
living-related renal transplant in [**2162**] from his mother.  Renal
biopsy of the allograft in [**2171-2-26**] showed chronic allograft
nephropathy.
-Coronary artery disease status-post IMI in
[**2161**] and multiple percutaneous coronary interventions.
-Diastolic heart failure
-Hypertension.
-Hyperlipidemia.
-History of upper extremity deep venous thrombosis, maintained
on Coumadin anticoagulation
-reactive airway disease
-s/p CCY [**12-3**]
-peripheral neuropathy
-Gerd
-splenomegaly
.
Cardiac Risk Factors: Diabetes(-), Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: -ASPIRIN - 325 MG TABLET qd
-Neoral 75 [**Hospital1 **]
-FOLIC ACID 1 qd
-B6 50 qd
-B12 100 qd
-Lisinopril 10 qd
-METHADONE - 20 mg tid
-METOPROLOL SUCCINATE 100 qd
-OXYCODONE - 15 mg q6 prn
-OXYCODONE [OXYCONTIN] - 20 mg tid
-PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **]
-PRAVASTATIN SODIUM - 80MG qhs
-PREDNISONE - 10 MG EVERY OTHER DAY
-WARFARIN - 2 qd

ALLERGIES: Cymbalta / Ativan

PHYSICAL EXAM: VS -  97  125/58  80  96/RA
Gen: WDWN middle aged male 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: Father with h/o DM, CAD s/p MI, bladder ca, renal cell ca;
Mother with h/o CAD, breast ca

SOCIAL HISTORY: He lives with his wife. Does not work->on disability.
Tob: h/o 5pack yr, quit for 10yrs, restarted 1 yr ago at
6cig/day
EtOH: rare
illicits: none
Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Other complications due to other cardiac device, implant, and graft,Kidney replaced by transplant,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy
Subendo infarct, initial,Ac on chr diast hrt fail,Comp-oth cardiac device,Kidney transplant status,Crnry athrscl natve vssl,Idio periph neurpthy NOS
Admission Date:  [**2175-4-17**]              Discharge Date:   [**2175-4-22**]

Date of Birth:  [**2135-6-30**]             Sex:   M

Service: MEDICINE

Allergies:
Cymbalta / Ativan

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Stress MIBI

History of Present Illness:
39 M w/ CAD s/p MI, s/p multiple PCI p/w CP. Pt started to have
CP when he was walking in a park w/ his wife. It was his
"familiar" CP. It went away by itself but came back again. He
called 911 and went to OSH when he was still having the CP.
There his EKG was normal and his first set of enzymes showed
trop I 0.00 (nl <0.08) at 1817 on [**4-16**] (no CK available). He was
started on IV heparin and IV nitro. He also received IV
morphine. he was CP free by 8 pm. his second set of enzymes
showed trop I 0.486 (nl <0.034) and CK 184 (nl <170)at 0430 on
[**4-17**]. repeat EKG again   showed NSR and no sig ST-T changes from
previous. He was xferred here for further mgmt.
.
In the CCU he denies CP, SOB. The CP did not recur since last
night.
.
On review of systems, he denies any prior history of stroke,
TIA,  pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. he denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.


Past Medical History:
-End-stage renal disease secondary to crescentic IgA
nephropathy, as diagnosed on renal biopsy in [**2161**], on
hemodialysis for approximately five months before receiving a
living-related renal transplant in [**2162**] from his mother.  Renal
biopsy of the allograft in [**2171-2-26**] showed chronic allograft
nephropathy.
-Coronary artery disease status-post IMI in
[**2161**] and multiple percutaneous coronary interventions.
-Diastolic heart failure
-Hypertension.
-Hyperlipidemia.
-History of upper extremity deep venous thrombosis, maintained
on Coumadin anticoagulation
-reactive airway disease
-s/p CCY [**12-3**]
-peripheral neuropathy
-Gerd
-splenomegaly
.
Cardiac Risk Factors: Diabetes(-), Dyslipidemia, Hypertension

Social History:
He lives with his wife. Does not work->on disability.
Tob: h/o 5pack yr, quit for 10yrs, restarted 1 yr ago at
6cig/day
EtOH: rare
illicits: none


Family History:
Father with h/o DM, CAD s/p MI, bladder ca, renal cell ca;
Mother with h/o CAD, breast ca

Physical Exam:
VS -  97  125/58  80  96/RA
Gen: WDWN middle aged male 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: difficult to assess JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.

Pulses:
Right: Carotid 2+ Femoral 2+  DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+  DP 2+ PT 2+


Pertinent Results:
[**2175-4-17**] 10:25PM   PTT-61.6*
[**2175-4-17**] 03:43PM   GLUCOSE-127* UREA N-36* CREAT-2.1* SODIUM-142
POTASSIUM-5.2* CHLORIDE-110* TOTAL CO2-24 ANION GAP-13
[**2175-4-17**] 03:43PM   CK(CPK)-147
[**2175-4-17**] 03:43PM   CK-MB-10 MB INDX-6.8* cTropnT-0.25*
[**2175-4-17**] 03:43PM   CALCIUM-9.4 PHOSPHATE-1.7* MAGNESIUM-1.8
[**2175-4-17**] 03:43PM   WBC-7.9 RBC-3.43* HGB-10.9* HCT-30.9* MCV-90
MCH-31.7 MCHC-35.3* RDW-14.9
[**2175-4-17**] 03:43PM   PLT COUNT-181
[**2175-4-17**] 03:43PM   PT-26.6* PTT-150* INR(PT)-2.6*

TTE [**2175-4-18**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with thinned and akinetic (mildly aneurysmal) basal
inferior and inferolateral segments. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.

Compared with the report of the prior study (images unavailable
for review) of [**2168-4-19**], basal inferior hypokinesis was
reported previously. Overall left ventricular systolic function
is probably similar.

ETT-MIBI:
INTERPRETATION: 39 yo man s/p multiple PCIs was referred to
evaluate
an atypical chest discomfort and elevated troponins. The patient

completed 7 minutes of a modified [**Doctor First Name **] protocol representing a
poor
exercise tolerance; ~ 5 METS. The exercise test was stopped
secondary to
rapidly progressive anginal symptoms. Early in exercise, the
patient
reported an anterior chest burning/heaviness and bilateral arm
discomfort and fatigue. Rapid progressive of these symptoms were
noted
during stage III of exercise and exercise was terminated;
symptoms [**8-7**].
The symptoms resolved quickly following rest and administration
of O2 nc
being absent 2 minutes post-exercise. No significant ST segment
changes
were noted during the procedure. The rhythm was sinus with no
ectopy
noted. The blood pressure response to exercise was appropriate.
In the
presence of beta blockade, and exercise-limiting symptoms, the
peak
exercise heart rate was blunted.

IMPRESSION: Anginal-LIMITING symptoms in the absence of ischemic
ST
segment changes. Nuclear report sent separately.

Cardiac catheterization: report pending.  RCA stenoses treated
with 4 taxus stents.

discharge Cr 2.1, hct stable.

Brief Hospital Course:
#. CAD: Pt had chest pain, similar to the ones he has had in
past and had enzyme elevation although no EKG changes. He ruled
for a NSTEMI with CK peak of 147. He was treated with heparin
gtt, continued on nitro gtt and plavix loaded. The nitro was
quickly weaned off without recurrence of angina. He was
continued ASA, toprol XL, ACEI, and plavix. Statin was increased
given cholesterol not at goal. ETT-MIBI was aborted for angina
after 1 minute of excercise. Therefore he underwent cardiac
catheterization with 4 taxus stents to his RCA.

#. diastolic CHF: Last echo in 02 showed EF of 45-55% and on TTE
here EF same however new apical akinesis. He was continued on
ACEI, statin, beta blocker, and asa.

#. H/o DVT: coumadin was held in preparation for potential cath
and was restarted prior to discharge.

#. S/p renal xplant: Creatinine stable at 2-2.5. Renal was
consulted and confirmed cyclosporine and prenisone doses and
patient was continued on this regimen.  He was given mucomyst
and bicarbonate prior to cardiac catheterization

#. Neuropathy: Patient was continued on oxycodone and methodone
per his home regimen with short-acting oxycodone prn as patient
has ADR with tylenol (a reported interaction between his
coumadin and acetominophen).

#. Code:  full

Medications on Admission:
-ASPIRIN - 325 MG TABLET qd
-Neoral 75 [**Hospital1 **]
-FOLIC ACID 1 qd
-B6 50 qd
-B12 100 qd
-Lisinopril 10 qd
-METHADONE - 20 mg tid
-METOPROLOL SUCCINATE 100 qd
-OXYCODONE - 15 mg q6 prn
-OXYCODONE [OXYCONTIN] - 20 mg tid
-PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **]
-PRAVASTATIN SODIUM - 80MG qhs
-PREDNISONE - 10 MG EVERY OTHER DAY
-WARFARIN - 2 qd


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Outpatient Lab Work
Please check INR, Chem 7 and CBC on Tuesday [**4-25**]. Please
call results to Dr. [**Last Name (STitle) 13959**] at [**Telephone/Fax (1) 250**].
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-31**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain:
If you still have chest pain after 3 tablets, call 911.
10. Methadone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO TID (3 times a day).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed: Please use for chest pain, can repeat
once, if does not relieve the pain, contact your MD.
[**Last Name (Titles) **]:*30 tabs* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Acute on chronic Congestive Heart Failure
Chronic Kidney Disease s/p renal transplant for IgA nephropathy
Left upper extremity DVT on chronic coumadin therapy
Hyperlipidemia
Peripheral Neuropathy on chronic narcotics
Hypertension


Discharge Condition:
good


Discharge Instructions:
You had a small heart attack and a cardiac catheterization
showed occlusions in your right coronary artery; you had 4 Taxus
stents placed in your right coronary artery with good effect.
Because of these stents you have been placed on plavix, which
you MUST CONTINUE FOR ONE YEAR at least.  Otherwise we have not
changed any of your medications.

Your coumadin has been held for several days in the hospital.
YOu should resume your regular 2mg coumadin daily and followup
in your coumadin clinic on Monday for an INR check.  We decided
against giving you lovenox.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.  Follow a 2000mg sodium diet.

Please call Dr.[**Name (NI) 3733**] or Dr. [**Last Name (STitle) 13959**] if you have any
unusual chest pain, nausea, sweating, trouble breathing,
increasing bruising, bleeding or tenderness in your right groin.
No baths or pools for one week. You may shower and change the
dressing on your right groin to a band-aid. No lifting more than
10 pounds for one week. No driving for 48 hours after the
catheterization.

If you have chest pain lasting longer than 10 minutes, or that
does not respond to 2 nitroglycerine then call 911.  If you have
other concerning symptoms like shortness of breath,
light-headedness, then seek medical attention.

Followup Instructions:
Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13960**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2175-4-27**] 10:00

Nephrology:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2175-7-6**] 2:30

Cardiology:
[**First Name4 (NamePattern1) 4648**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: [**5-16**] at
2:20pm.
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Other complications due to other cardiac device, implant, and graft,Kidney replaced by transplant,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy'}


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: 39 M w/ CAD s/p MI, s/p multiple PCI p/w CP. Pt started to have
CP when he was walking in a park w/ his wife. It was his
"familiar" CP. It went away by itself but came back again. He
called 911 and went to OSH when he was still having the CP.
There his EKG was normal and his first set of enzymes showed
trop I 0.00 (nl <0.08) at 1817 on [**4-16**] (no CK available). He was
started on IV heparin and IV nitro. He also received IV
morphine. he was CP free by 8 pm. his second set of enzymes
showed trop I 0.486 (nl <0.034) and CK 184 (nl <170)at 0430 on
[**4-17**]. repeat EKG again   showed NSR and no sig ST-T changes from
previous. He was xferred here for further mgmt.
.
In the CCU he denies CP, SOB. The CP did not recur since last
night.
.
On review of systems, he denies any prior history of stroke,
TIA,  pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. he denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: -End-stage renal disease secondary to crescentic IgA
nephropathy, as diagnosed on renal biopsy in [**2161**], on
hemodialysis for approximately five months before receiving a
living-related renal transplant in [**2162**] from his mother.  Renal
biopsy of the allograft in [**2171-2-26**] showed chronic allograft
nephropathy.
-Coronary artery disease status-post IMI in
[**2161**] and multiple percutaneous coronary interventions.
-Diastolic heart failure
-Hypertension.
-Hyperlipidemia.
-History of upper extremity deep venous thrombosis, maintained
on Coumadin anticoagulation
-reactive airway disease
-s/p CCY [**12-3**]
-peripheral neuropathy
-Gerd
-splenomegaly
.
Cardiac Risk Factors: Diabetes(-), Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: -ASPIRIN - 325 MG TABLET qd
-Neoral 75 [**Hospital1 **]
-FOLIC ACID 1 qd
-B6 50 qd
-B12 100 qd
-Lisinopril 10 qd
-METHADONE - 20 mg tid
-METOPROLOL SUCCINATE 100 qd
-OXYCODONE - 15 mg q6 prn
-OXYCODONE [OXYCONTIN] - 20 mg tid
-PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **]
-PRAVASTATIN SODIUM - 80MG qhs
-PREDNISONE - 10 MG EVERY OTHER DAY
-WARFARIN - 2 qd

ALLERGIES: Cymbalta / Ativan

PHYSICAL EXAM: VS -  97  125/58  80  96/RA
Gen: WDWN middle aged male 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: Father with h/o DM, CAD s/p MI, bladder ca, renal cell ca;
Mother with h/o CAD, breast ca

SOCIAL HISTORY: He lives with his wife. Does not work->on disability.
Tob: h/o 5pack yr, quit for 10yrs, restarted 1 yr ago at
6cig/day
EtOH: rare
illicits: none 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic diastolic heart failure,Other complications due to other cardiac device, implant, and graft,Kidney replaced by transplant,Coronary atherosclerosis of native coronary artery,Unspecified hereditary and idiopathic peripheral neuropathy'}
