CHIEF COMPLAINT: chest pain and SOB

PRESENT ILLNESS: 69 yo female with PMHx of CAD s/p MI 9 year ago, diastolic
dysfuction with EF of 65%, IDDM, hyperlipidemia, hypothroirid,
COPD on 2L home O2 presented to [**Hospital 1474**] Hospital with
complaints of SOB and chest pain  for 2 days and was noted to be
pale and diaporhetic and bradycardic at the OSH wirh HR in the
40's and BP in 80's. He was started on nitro gtt, heparin gtt,
and atropine was given. SHe was persistantly bradycardic and
then required dopamine. She had elevated Ck and troponins and
was transferred here for further evalution.

MEDICAL HISTORY: Vertigo
endocarditis 2 years ago
RA
gastritis
Hypothyroidism
Depression
Carpal tunnel syndrome
Hypertension
Hyperlipidimia
Heart Failure

MEDICATION ON ADMISSION: ASA 325, Avapro 75, Cardizem 300, cyclobenzaoime 10, Fosamax 70,
Lasix 60, Isosorbide 40 TID, Levoxyl 150, Lipitor 80, Nadolol
20, Zoloft 100, Insulin NPH 66 ans Humalog 12 qAM, Insulin NPH
70 and Humalog 12 qPM

ALLERGIES: Penicillins / Vicodin / Relafen / Diclofenac / Bactrim / Keflex
/ Voltaren / [**Doctor First Name **]

PHYSICAL EXAM: Vitals: T= 97.8, HR = 59, BP = 124/63, RR =23, SaO2 = 92% on
100% face mask.
General: appears uncomfortable, in distress.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Obese neck. JVP difficult to assess
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs had coarse breath sounds bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing, trace edema with 1+ dorsalis
pedis pulses bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: Does not smoke of drink.
Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other second degree atrioventricular block,Congestive heart failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Obesity, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia
Subendo infarct, initial,Crnry athrscl natve vssl,Av block-2nd degree NEC,CHF NOS,Other pulmonary insuff,Acute kidney failure NOS,DMII keto nt st uncntrld,Mitral valve disorder,Chr airway obstruct NEC,Anemia-other chronic dis,Obesity NOS,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2116-11-28**]              Discharge Date:   [**2116-12-10**]

Date of Birth:  [**2047-9-3**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Vicodin / Relafen / Diclofenac / Bactrim / Keflex
/ Voltaren / [**Doctor First Name **]

Attending:[**First Name3 (LF) 106**]
Chief Complaint:
chest pain and SOB

Major Surgical or Invasive Procedure:
Cardiac cath


History of Present Illness:
69 yo female with PMHx of CAD s/p MI 9 year ago, diastolic
dysfuction with EF of 65%, IDDM, hyperlipidemia, hypothroirid,
COPD on 2L home O2 presented to [**Hospital 1474**] Hospital with
complaints of SOB and chest pain  for 2 days and was noted to be
pale and diaporhetic and bradycardic at the OSH wirh HR in the
40's and BP in 80's. He was started on nitro gtt, heparin gtt,
and atropine was given. SHe was persistantly bradycardic and
then required dopamine. She had elevated Ck and troponins and
was transferred here for further evalution.

She states that over the past few dys she has had increased
episodes of jaw pain (her anginal equlivant) with increased DOE
and orthopnea. She was told to double her Lasix doses on Friday
by PCP and was prescribed an antiobiotic tht she does not know
the name of.

ROS: Jaw pain, DOE with a few feet, increased orthopnea with 2
pillows, no edema or palpitations. No syncope

Past Medical History:
Vertigo
endocarditis 2 years ago
RA
gastritis
Hypothyroidism
Depression
Carpal tunnel syndrome
Hypertension
Hyperlipidimia
Heart Failure

Social History:
Does not smoke of drink.

Family History:
NC

Physical Exam:
Vitals: T= 97.8, HR = 59, BP = 124/63, RR =23, SaO2 = 92% on
100% face mask.
General: appears uncomfortable, in distress.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Obese neck. JVP difficult to assess
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs had coarse breath sounds bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing, trace edema with 1+ dorsalis
pedis pulses bilaterally


Pertinent Results:
EKG: 2:1 AV block. ST depression in I, AVL, V4 - 6. increased PR
interval

CXR: Bilateral pleural effusion and in creased pulm vasculature

CATH:
1. Selective coronary angiography demonstrated one vessel
coronary
artery disease in a left dominant system.  The LMCA and LAD had
no
angiographically apparent CAD. The RCA was a small non-dominant
vessel
that filled only acute marginal branches. The LCx had a proximal
30%
stenosis. The OM1 came off the circumfle distally and was
completely
occluded. The OM2 came off at the same level as the OM1 and had
a 90%
proximal stenosis.  The distal circumflex was totally occluded.
2. Limited hemodynamics revealed normal left heart filling
pressures and
a preserved cardiac output.
3. Left ventriculography was not performed due to concerns about
excess
dye load.
4. Successful placement of 3.5 x 13 mm Cypher drug-eluting stent
in the
proximal LCx. Final angiography demonstrated no residual
stenosis in the
proximal vessel, no angiographically apparent dissection, and
normal
flow (See PTCA Comments).
5. Unsuccessful attempt to treat OM1 branch with balloon
angioplasty or
stenting due to inability to cross chronically occluded lesion
with
wire. Final angiography demonstrated no change in the total
occlusion
and no angiographically apparent dissection (See PTCA Comments).

6. Successful balloon angioplasty of the OM2 branch with a
maximal 2.0
mm balloon. Final angiography demonstrated a 20% residual
stenosis, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
7. Successful placement of three overlapping Cypher drug-eluting
stents
in the distal LCx (proximal 3.0 x 8 mm, mid 2.5 x 8 mm, and
distal 2.5 x
2) all post-dilated with a 3.0 x 15 mm Quantum Maverick balloon.
Final
angiography demonstrated no residual stenosis, no
angiographically
apparent dissection, and normal flow (See PTCA Comments).

FINAL DIAGNOSIS:
1. One vessel coronary artery disease
2. Normal left heart filling pressures
4. Successful placement of drug-eluting stent in proximal LCx.
5. Unsuccessful attempt to cross totally occluded OM1 branch.
6. Successful balloon angioplasty of OM2 branch.
6. Successful placement of three overlapping drug-eluting stents
in
distal LCx.

ECHO: EF 60-65%, 2+ MR, 1+ TR.


Brief Hospital Course:
1. Rhythm: The patient was in new 2:1 heart block with
bradycardia to the 30 - 40s and low systolic BP, no urine
output, and decreased mental status when admitted. Pacer pads
were placed and an emergent cordis was inserted into her right
IJ for pacer wires. The patient was paced breifly at a rate of
70 and regained a faster native heart rate by the evening. She
began to make urine and her mental status improved with this
intervention. As her blood pressure began to increase, her
dopamine was weaned off.  Pt only required temp pacer for the
first few days, and remained in normal rate/tachycardia.  Pt
developed frequent PVC's and bigeminy's when she was
hypertensive/tachycardic, and PO metoprolol was added for rate
control and BP control.  Pt has remained in normal sinus rhythm
with occasional PVC's for rest of the hospital course.

2. CAD: Most likely coronary disease in the setting of new EKG
changes  and 2:1 block.  She was ruled in by enzymes with peak
troponin of 1.77.  She was started on ASA, statin.  Beta-blocker
was initially held given bradycardia and heart block, but later
re-started.  ACEI was also held for ARF prior to cath.  She has
had recurrent CP which responded to nitro and morphine.  Pt was
on heparin gtt and nitro gtt when she came in.  Heparin gtt was
continued.  Nitro gtt was initially weaned but re-started for BP
control.  Cath was postponed due to acute renal failure
initially, and also later for respiratory distress from
penumonia(febrile)/CHF later.  Pt underwent cath once creatinine
normalized to her baseline, and her respiratory status improved
after antibiotics and diuresis.  Cath showed the LMCA and LAD
had no angiographically apparent CAD. The RCA was a small
non-dominant vessel that filled only acute marginal branches.
The LCx had a proximal 30%
stenosis. The OM1 came off the circumflex distally and was
completely occluded. The OM2 came off at the same level as the
OM1 and had a 90% proximal stenosis.  The distal circumflex was
totally occluded. Successful drug-eluting stents placement in
proximal LCx x1 stent, 2 over lapping stents in distal LCx,
balloon angioplasty of OM2.

3. Pump: Diastolic CHF with EF 65%. CXR and clinical history are
c/w CHF excerbation. Pt has a hx of endocarditis, TTE showed
2+MR but no obvious vegetations.  Pt went into flash pulm edema
requiring IV lasix for diuresis.  Swan was placed since pt
remained on NRB/BIPAP for several days despite diuresis.  PCWP
was in the 20's so pt was aggressively diuresed further with IV
lasix until PCWP was 11.  Her dry weight when PCWP 11 was 114
kg.  Pt was discharged with standing po lasix 60 mg qd (homeo
dose)+ potassium supplement.  Pt was instructed to weigh herself
daily to keep her wt at or below 114 kg.

4. Respiratoy failure: Pt has been using home O2 for unclear
reason.  Pt has no hx of COPD and no hx of smoking.  She was
recently diagnosed with a pneumonia by her PCP and was started
on levofloxacin prior to admission. When admitted,she was very
difficult to oxygenate despite NRB. She was started on
levofloxacin but remained febrile, so vancomycin and flagyl were
added with improvement in symptoms and WBC.  Pt was diuresed neg
1L daily without improvement in her respiratory symptoms.
Swan-Ganz catheter was placed which showed PCWP of 20's.  Pt was
then aggressively diuresed with IV lasix until PCWP of 11.  She
was eventually weaned off to NC 2.5 L.  However, pt still
desaturate to mid 80's on 3L NC with ambulation, and also at
night while she is asleep.  PFT's were done which showed
restrictive pattern most likely from obesity.  FVC 42%, FEV144%,
FEV1/FVC 102%, ERV 1%.  Also, pt most likely has sleep apnea
component as well and should get an outpatient sleep study.  Pt
was discharged with home O2 since she destaturated to mid 80's
with physical therapy activity.

5. DKA: The paitent missed a dose of insulin the morning of
admittance. he had an elevated blood glucose and an anion gap of
19. She was started on an insulin drip requiring up to 28 units
per hour. Her gap then normalized and she was started on a
sliding scale.  Pt resumed her home regimen of NPH and humalog
and was stable.

6. Acute renal failure: Cr 3.1 on admission (baseline 1.6 per
PCP), most likely secondary to decreased C.O. in a setting of
NSTEMI and bradycardia.  Pt initially had low UOP but improved
after temp pacer was placed to treat bradycardia.  Creatinine
came down to as low as 1.2.  However, after aggressively
diuresing her for CHF, her Cr came up to 1.8 at the time of
discharge.

7.Anemia: Hct of 29 on admission but drifted down to 26.  Pt got
2 units of PRBC but with inappropriate response.  Guiac was
negative.  Iron studies were consistent with anemia of chronic
disease.  Most likely from her renal disease.  Pt needs an
outpatient follow up of her anemia since she may benefit from
Epogen.  Pt would should have her PCP refer her to a
nephorologist if her Hct continues to trend down.

8. ID: Pt was diagnosed with pneumonia prior to admission and
received levofloxacin by her PCP.  [**Name10 (NameIs) **] was continued on
levofloxacin but continued to have fever and leukocytosis with
CXR with no improvement.  Vancomycin and flagyl were added with
improvement in symptoms.  Levo and Flagyl were eventually
discontinued.  Although none of her cultures grew anything, she
was treated with presumed MRSA pneumonia since she responded to
Vanc and not Levo.  She will complete a 14 day course of IV
Vancomycin.

Medications on Admission:
ASA 325, Avapro 75, Cardizem 300, cyclobenzaoime 10, Fosamax 70,
Lasix 60, Isosorbide 40 TID, Levoxyl 150, Lipitor 80, Nadolol
20, Zoloft 100, Insulin NPH 66 ans Humalog 12 qAM, Insulin NPH
70 and Humalog 12 qPM

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Potassium Chloride 20 mEq Packet Sig: One (1)  PO DAILY
(Daily).
Disp:*30 * Refills:*2*
9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1)  Intravenous
once a day for 3 days.
Disp:*3000 mg* Refills:*0*
10. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as
directed  Subcutaneous once a day: 66 units NPH in AM, 70 units
NPH in PM.
11. Humalog 100 unit/mL Solution Sig: as directed  Subcutaneous
twice a day: 12 units in AM and 12 units in PM.
12. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a day.
15. Avapro 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
CHF
Pneumonia
CAD s/p cath
CRI
Anemia


Discharge Condition:
Hemodynamically stable, breathing comfortably on 2.5L NC.

Discharge Instructions:
Patient was instructed to take all of the medications as
indicated.  Patient needs to seek medical attention if she
develops shortness of breath, chest pain, fatigue, dizziness,
increased weight, decrease in urine output.  Patient needs to
weigh herself daily and seek medical attention (PCP,
[**Name Initial (NameIs) 2085**]) if she has more than 2 kg weight gain.  She had a
low sodium, cardiac, and diabetic diet instruction and should
continue that at home.

Followup Instructions:
Follow up with PCP [**Last Name (NamePattern4) **] [**1-3**] weeks.
Follow up with her cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**2-5**] weeks.

Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2117-1-8**]
8:55
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2117-1-8**] 9:10
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 611**]/DR. [**Last Name (STitle) **] Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 5091**] Date/Time:[**2117-1-8**] 9:10



Completed by:[**2116-12-11**]
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other second degree atrioventricular block,Congestive heart failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Obesity, 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 and SOB

PRESENT ILLNESS: 69 yo female with PMHx of CAD s/p MI 9 year ago, diastolic
dysfuction with EF of 65%, IDDM, hyperlipidemia, hypothroirid,
COPD on 2L home O2 presented to [**Hospital 1474**] Hospital with
complaints of SOB and chest pain  for 2 days and was noted to be
pale and diaporhetic and bradycardic at the OSH wirh HR in the
40's and BP in 80's. He was started on nitro gtt, heparin gtt,
and atropine was given. SHe was persistantly bradycardic and
then required dopamine. She had elevated Ck and troponins and
was transferred here for further evalution.

MEDICAL HISTORY: Vertigo
endocarditis 2 years ago
RA
gastritis
Hypothyroidism
Depression
Carpal tunnel syndrome
Hypertension
Hyperlipidimia
Heart Failure

MEDICATION ON ADMISSION: ASA 325, Avapro 75, Cardizem 300, cyclobenzaoime 10, Fosamax 70,
Lasix 60, Isosorbide 40 TID, Levoxyl 150, Lipitor 80, Nadolol
20, Zoloft 100, Insulin NPH 66 ans Humalog 12 qAM, Insulin NPH
70 and Humalog 12 qPM

ALLERGIES: Penicillins / Vicodin / Relafen / Diclofenac / Bactrim / Keflex
/ Voltaren / [**Doctor First Name **]

PHYSICAL EXAM: Vitals: T= 97.8, HR = 59, BP = 124/63, RR =23, SaO2 = 92% on
100% face mask.
General: appears uncomfortable, in distress.
HEENT: Normocephalic and atraumatic head, no nuchal rigidity,
anicteric sclera, moist mucous membranes.
Neck: No thyromegaly, no lymphadenopathy, no carotid bruits.
Obese neck. JVP difficult to assess
Chest: Her chest rose and fell with equal size, shape and
symmetry, her lungs had coarse breath sounds bilaterally.
CV: PMI appreciated in the fifth ICS in the midclavicular line
without heaves or thrills, RRR, normal S1 and S1 no murmurs rubs
or gallops.
Abd: Normoactive BS, NT and ND. No masses or organomegaly
Back: No spinal or CVA tenderness.
Ext: NO cyanosis, no clubbing, trace edema with 1+ dorsalis
pedis pulses bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: Does not smoke of drink. 

### Response:
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Other second degree atrioventricular block,Congestive heart failure, unspecified,Other pulmonary insufficiency, not elsewhere classified,Acute kidney failure, unspecified,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Anemia of other chronic disease,Obesity, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia'}
