CHIEF COMPLAINT: ST-elevation myocardial infarction

PRESENT ILLNESS: Pt is 87 yo [**First Name3 (LF) 8230**] speaking m with HTN, dyslipidemia, who
began having chest pain and back pain at his nursing home at 1
pm. He had elevated CK, and abnormal EKG so he was brought to
the [**Hospital1 18**] ED at 2 AM. He received 2 SL ntg's prior to arrival.
.
In the ED, EKG showed anterolateral ST elevations, trop 11.3. He
was given ASA 325mg PO prior to arrrival, then plavix 600mg PO,
heparin gtt, and integrillin gtt. He was brought to the cath
lab, found to have a 95% mid LAD lesion, thrombectomy was
performed, and a BMS was placed to the LAD.
.
Pt currently has no complaints and denies CP/SOB.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, 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 dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations. He does have history of syncope and falls.
.

MEDICAL HISTORY: HTN
Dyslipidemia
s/p R hip arthroplasty
h/o syncope
h/o falls
L eye enucleation
dementia
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: none
.
Pacemaker/ICD: none

MEDICATION ON ADMISSION: MEDICATIONS (at NH):
Lisinopril 10mg daily
MVI
Famotidine 20mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Metoprolol 12.5mg [**Hospital1 **]
Senna 2 tabs qhs
MOM 30ml prn
Fleet enema daily prn
Tylenol with codeine 300/30 q4h prn
Maalox 30ml q4h prn
.
MEDICATIONS (on transfer from cath lab):
Plavix 75mg daily
ASA 325mg daily
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: S: T 94.6, BP 101/52 , HR 60, RR 16, O2 97 % on 2L NC
Gen: elderly male, somnolent, NAD. dry MM. Arousable to loud
voice, responds only intermittently to commands. A&O only to
name.
HEENT: L eye enucleation.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RRR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: all 4 ext cool. RLE with purple color compared to LLE.
Skin: RLE with purple color compared to LLE.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
MEDICAL DECISION MAKING
.
EKG (at NH): NSR @ 73, LAD, QW II, III, V1-V6, STE I, II, III,
aVF, V2-V6, TWI aVL, TWF V4-V6
.
EKG ([**Hospital1 18**], pre-cath): no change from OSH.
.
EKG ([**Hospital1 18**], post-cath): NSR @ 84, LAD, QW II, III, V1-V6, STE I,
II, III, aVF, V2-V6 (more pronounced V3-V6), TWI aVL, TWF V4-V6
.
TELEMETRY demonstrated: NSR
.
CARDIAC CATH performed on [**2136-4-19**] demonstrated:
LAD: 95% thrombotic mid, moderate diffuse distal disease
LCX: ectopic off right cusp with 80% proximal (small vessel),
diffuse disease in OM
RCA: 40% mid, 70% mid PDA
Export thrombectomy of mid LAD followed by bare metal stenting.

FAMILY HISTORY: Non-contributory in this 87 year old man

SOCIAL HISTORY: Quit smoking >20 yrs ago. No EtOH. Was a farmer in [**Country 651**] before
coming here several decades ago; has 9 children.
Acute myocardial infarction of anterolateral wall, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Other and unspecified hyperlipidemia
AMI anterolateral, init,Ac/chr syst/dia hrt fail,Other postop infection,Septicemia NOS,Severe sepsis,Acute kidney failure NOS,Pneumonia, organism NOS,Crnry athrscl natve vssl,Mental disor NEC oth dis,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2136-4-19**]              Discharge Date:   [**2136-4-30**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
ST-elevation myocardial infarction

Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to LAD

History of Present Illness:
Pt is 87 yo [**First Name3 (LF) 8230**] speaking m with HTN, dyslipidemia, who
began having chest pain and back pain at his nursing home at 1
pm. He had elevated CK, and abnormal EKG so he was brought to
the [**Hospital1 18**] ED at 2 AM. He received 2 SL ntg's prior to arrival.
.
In the ED, EKG showed anterolateral ST elevations, trop 11.3. He
was given ASA 325mg PO prior to arrrival, then plavix 600mg PO,
heparin gtt, and integrillin gtt. He was brought to the cath
lab, found to have a 95% mid LAD lesion, thrombectomy was
performed, and a BMS was placed to the LAD.
.
Pt currently has no complaints and denies CP/SOB.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, 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 dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations. He does have history of syncope and falls.
.

Past Medical History:
HTN
Dyslipidemia
s/p R hip arthroplasty
h/o syncope
h/o falls
L eye enucleation
dementia
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: none
.
Pacemaker/ICD: none

Social History:
Quit smoking >20 yrs ago. No EtOH. Was a farmer in [**Country 651**] before
coming here several decades ago; has 9 children.

Family History:
Non-contributory in this 87 year old man

Physical Exam:
S: T 94.6, BP 101/52 , HR 60, RR 16, O2 97 % on 2L NC
Gen: elderly male, somnolent, NAD. dry MM. Arousable to loud
voice, responds only intermittently to commands. A&O only to
name.
HEENT: L eye enucleation.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RRR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: all 4 ext cool. RLE with purple color compared to LLE.
Skin: RLE with purple color compared to LLE.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
MEDICAL DECISION MAKING
.
EKG (at NH): NSR @ 73, LAD, QW II, III, V1-V6, STE I, II, III,
aVF, V2-V6, TWI aVL, TWF V4-V6
.
EKG ([**Hospital1 18**], pre-cath): no change from OSH.
.
EKG ([**Hospital1 18**], post-cath): NSR @ 84, LAD, QW II, III, V1-V6, STE I,
II, III, aVF, V2-V6 (more pronounced V3-V6), TWI aVL, TWF V4-V6
.
TELEMETRY demonstrated: NSR
.
CARDIAC CATH performed on [**2136-4-19**] demonstrated:
LAD: 95% thrombotic mid, moderate diffuse distal disease
LCX: ectopic off right cusp with 80% proximal (small vessel),
diffuse disease in OM
RCA: 40% mid, 70% mid PDA
Export thrombectomy of mid LAD followed by bare metal stenting.


Pertinent Results:
OSH labs: ALT 73, AST 486, WBC 10.4, CK 3781.
.
.
[**2136-4-19**] 02:00AM   cTropnT-11.3*
[**2136-4-19**] 08:01AM   CK-MB-240* MB INDX-8.1* cTropnT-20.05*
[**2136-4-19**] 03:33PM   CK-MB-98* MB INDX-5.0
[**2136-4-19**] 03:33PM   CK(CPK)-[**2097**]*
.
[**2136-4-19**] 06:36AM   TYPE-ART PO2-131* PCO2-37 PH-7.43 TOTAL
CO2-25 BASE XS-1
[**2136-4-19**] 09:14PM   LACTATE-1.7
[**2136-4-19**] 09:14PM   TYPE-[**Last Name (un) **] PO2-50* PCO2-42 PH-7.37 TOTAL CO2-25
BASE XS-0
[**2136-4-19**] 10:48PM   O2 SAT-63
.
[**2136-4-19**] 02:00AM   WBC-14.9* RBC-4.73 HGB-14.7 HCT-45.2 MCV-96
MCH-31.1 MCHC-32.6 RDW-14.4  PLT COUNT-215
[**2136-4-19**] 08:01AM   WBC-13.1* RBC-4.10* HGB-12.9* HCT-38.9*
MCV-95 MCH-31.5 MCHC-33.1 RDW-14.8// NEUTS-83.4* LYMPHS-9.6*
MONOS-6.4 EOS-0.5 BASOS-0.2
[**2136-4-19**] 03:33PM   WBC-10.8 RBC-3.95* HGB-12.3* HCT-37.4* MCV-95
MCH-31.2 MCHC-32.9 RDW-14.5 PLT COUNT-175
.
[**2136-4-19**] 02:00AM   GLUCOSE-110* UREA N-28* CREAT-1.0 SODIUM-136
POTASSIUM-5.1 CHLORIDE-101 TOTAL CO2-19* ANION GAP-21*
[**2136-4-19**] 08:01AM   GLUCOSE-121* UREA N-26* CREAT-0.8 SODIUM-135
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-23 ANION GAP-15
[**2136-4-19**] 08:01AM   ALT(SGPT)-78* AST(SGOT)-481* LD(LDH)-1337*
CK(CPK)-2959* ALK PHOS-66 TOT BILI-1.2
[**2136-4-19**] 08:01AM   ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-3.1
MAGNESIUM-2.2 CHOLEST-137
[**2136-4-19**] 08:01AM   TRIGLYCER-31 HDL CHOL-67 CHOL/HDL-2.0
LDL(CALC)-64
.
[**2136-4-19**] 08:01AM   ACETMNPHN-NEG
.
[**2136-4-19**] 09:45AM URINE  COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2136-4-19**] 09:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
.
.

Brief Hospital Course:
.
[**Known firstname **] [**First Name8 (NamePattern2) 1255**] [**Known lastname 20451**] was an 87 year old man who presented to [**Hospital1 18**]
with an anterolateral STEMI, likely evolving for a time prior to
admission. During cardiac catheterization he was found to have
95% mid LAD thrombotic lesion, which was stented with a bare
metal stent. In the night after the procedure, he was febrile
and hypotensive,  required pressors, and having put in a right
internal jugular Cordis, his Swan numbers suggested cardiogenic
shock with septic contribution. His blood cultures remained
negative but he was treated empirically for possible
hospital-acquired pneumonia (given earlier nursing home stay)
with piperacillin-tazobactam and vancomycin. He improved
somewhat from a hemodynamic point of view, improving his
apparent forward flow, and remaining afebrile after the first
days of his admission.
.
However, his mental status waxed and waned and he did have some
problems with sundowning; as the admission went on, it became
also clear that he became less responsive and more confused when
dopamine was turned off, including agitation that was only
mildly responsive to anti-psychotic treatment (olanzapine) and
required soft restratints for a time to prevent the patient from
pulling out his lines. We pulled his Foley, dressed his RIJ line
so that he could not pull it, and restarted dopamine which had
the effect of reducing his agitation.
.
We continued to make efforts to communicate with the patient
through a [**Name (NI) 8230**] interpreter and through his family.
Additionally, several members of the medical staff (a resident
and the palliative care consulting attending, as well as a
cardiology fellow assisting with a heart failure consult) were
able to have basic communication with him by speaking some
Mandarin, which the patient appeared to be able to understand.
Unfortunately, whether in [**Name (NI) 8230**] or Mandarin, the patient was
not entirely coherent even at this best, and was not able to
communicate much in the way of history or description of current
state; his family members said they were understanding as little
as a quarter of what he was trying to say.
.
Two echocardiograms early in the admission ([**4-19**] and [**4-20**])
showed diminished ejection fraction (the second showing
LVEF=35%), and apical and mid-left ventricular akinesis, as well
as moderate-to-severe AR and mild-to-moderate MR.  It is likely
that his valvular disease decreased his forward flow more than
his LVEF would indicate, given that his cardiac output when
measured by Swan was generally quite low, and he was
dopamine-dependent for most of the admission. We found that even
when we attempted to reduce afterload in conjunction with
reducing dopamine, his mental status deteriorated and he became
barely responsive when not on dopamine during the second week of
his admission. Additionally, in consideration of the possibility
of hospice we contemplated theophylline and Sinemet as
substitutes for dopamine, but ultimately it became clear that he
would either require dopamine or have comfort care. The relation
between dopamine and mental status was effectively demonstrated
by two attempts to wean off dopamine in which mental status
markedly declined, and then revival of interactivity and
lessening of agitation when dopamine was restarted.

We discussed goals of care with the family, emphasizing that we
did not expect any significant recovery from his cardiac injury.
Palliative care was consulted and the palliative care attending
physician also discussed goals of care with the family on [**4-25**]. They understood the difficulties of his medical situation
but hoped to delay changing goals of care until other members of
the family could arrive. They did, however, agree to make Mr
[**Known lastname 20451**] DNR/DNI in the meantime. The cardiac care unit team agreed
to this plan and emphasized trying to maintain adequate
perfusion and mental status until more of the family could be
present over the weekend.
.
By the night of [**4-28**], most of the far-flung family had
arrived, and a large family meeting was conducted with all
family members, in which we emphasized that we did not expect Mr
[**Known lastname 20451**] to be able to function without dopamine, and pointed out
that we expected either a rapid decline without dopamine or a
slow but unpredictable (and possibly just as rapid) decline even
with more aggressive critical-care-level care, including
dopamine. Even before dopamine was stopped, Mr [**Known lastname 20451**] was having
increased episodes of apnea, and for the last two days had a
need for oxygen by nasal cannula.
.
After deliberation, and after another of the patient's nine
children was able to arrive from a flight from [**State 8842**] on the
morning of the 25th, the family and the medical and nursing
teams all agreed that the most appropriate plan of care was
comfort measures while the patient could be in the presence of
his family. Dopamine and other medications were discontinued and
morphine was started.
.
Mr [**Known lastname 20451**] died in the cardiac care unit in the morning of [**2136-4-30**],
having been surrounded by many members of his large extended
family for his last days. Before we turned off dopamine and for
a short time afterwards, Mr [**Known lastname 20451**] had clearly been able to
register and recognize his family's presence, and indeed
appeared to rally considerably in their presence, before fading
from consciousness as his cardiac and respiratory function
gradually slowed and lost effectiveness in the absence of
dopamine and other cardiac medications. Morphine was used and
appeared to be successful in preventing and treating respiratory
distress, pain and discomfort.
.
.

Medications on Admission:
MEDICATIONS (at NH):
Lisinopril 10mg daily
MVI
Famotidine 20mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Metoprolol 12.5mg [**Hospital1 **]
Senna 2 tabs qhs
MOM 30ml prn
Fleet enema daily prn
Tylenol with codeine 300/30 q4h prn
Maalox 30ml q4h prn
.
MEDICATIONS (on transfer from cath lab):
Plavix 75mg daily
ASA 325mg daily
.

Discharge Medications:
N/A

Discharge Disposition:
Expired

Discharge Diagnosis:
Death caused by acute-on-chronic systolic and diastolic heart
failure secondary to STEMI.

Discharge Condition:
Expired

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: ST-elevation myocardial infarction

PRESENT ILLNESS: Pt is 87 yo [**First Name3 (LF) 8230**] speaking m with HTN, dyslipidemia, who
began having chest pain and back pain at his nursing home at 1
pm. He had elevated CK, and abnormal EKG so he was brought to
the [**Hospital1 18**] ED at 2 AM. He received 2 SL ntg's prior to arrival.
.
In the ED, EKG showed anterolateral ST elevations, trop 11.3. He
was given ASA 325mg PO prior to arrrival, then plavix 600mg PO,
heparin gtt, and integrillin gtt. He was brought to the cath
lab, found to have a 95% mid LAD lesion, thrombectomy was
performed, and a BMS was placed to the LAD.
.
Pt currently has no complaints and denies CP/SOB.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, 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 dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations. He does have history of syncope and falls.
.

MEDICAL HISTORY: HTN
Dyslipidemia
s/p R hip arthroplasty
h/o syncope
h/o falls
L eye enucleation
dementia
.
Cardiac Risk Factors: Dyslipidemia, Hypertension
.
Cardiac History: none
.
Pacemaker/ICD: none

MEDICATION ON ADMISSION: MEDICATIONS (at NH):
Lisinopril 10mg daily
MVI
Famotidine 20mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Metoprolol 12.5mg [**Hospital1 **]
Senna 2 tabs qhs
MOM 30ml prn
Fleet enema daily prn
Tylenol with codeine 300/30 q4h prn
Maalox 30ml q4h prn
.
MEDICATIONS (on transfer from cath lab):
Plavix 75mg daily
ASA 325mg daily
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: S: T 94.6, BP 101/52 , HR 60, RR 16, O2 97 % on 2L NC
Gen: elderly male, somnolent, NAD. dry MM. Arousable to loud
voice, responds only intermittently to commands. A&O only to
name.
HEENT: L eye enucleation.
Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
Distant heart sounds. RRR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: all 4 ext cool. RLE with purple color compared to LLE.
Skin: RLE with purple color compared to LLE.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit;
dopplerable DP/PT
MEDICAL DECISION MAKING
.
EKG (at NH): NSR @ 73, LAD, QW II, III, V1-V6, STE I, II, III,
aVF, V2-V6, TWI aVL, TWF V4-V6
.
EKG ([**Hospital1 18**], pre-cath): no change from OSH.
.
EKG ([**Hospital1 18**], post-cath): NSR @ 84, LAD, QW II, III, V1-V6, STE I,
II, III, aVF, V2-V6 (more pronounced V3-V6), TWI aVL, TWF V4-V6
.
TELEMETRY demonstrated: NSR
.
CARDIAC CATH performed on [**2136-4-19**] demonstrated:
LAD: 95% thrombotic mid, moderate diffuse distal disease
LCX: ectopic off right cusp with 80% proximal (small vessel),
diffuse disease in OM
RCA: 40% mid, 70% mid PDA
Export thrombectomy of mid LAD followed by bare metal stenting.

FAMILY HISTORY: Non-contributory in this 87 year old man

SOCIAL HISTORY: Quit smoking >20 yrs ago. No EtOH. Was a farmer in [**Country 651**] before
coming here several decades ago; has 9 children. 

### Response:
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute on chronic combined systolic and diastolic heart failure,Other postoperative infection,Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
