CHIEF COMPLAINT: SOB and epigastric burning

PRESENT ILLNESS: This is a 66 y/o F with h/o HTN and carotid disease s/p R CEA
(in [**2155**]) who initially presented to OSH with shortness of
breath and epigastric burning. This started while patient was
vomiting (non-bilious/non-bloody) and worsened when she walked
around home. Stated that nausea/vomiting/epigastric pain had
been presented with "few days" prior to admission. On day of
presentation, pain was worsening, so she decided to come into
hosptial.
.
At OSH, patient was given "GI cocktail," aspirin 162mg, zofran,
protonix, and morphine 2mg with adequate relief of pain. Per
report from OSH, EKG had Q waves in inferior leads and ST
depressions in V3-V6. Trop were noted be 5.89 followed by 13.47.
Was then started on heparin gtt. Patient continued to have chest
discomfort and was started on nitro paste. Of note patient also
received plavix 300mg x 1. Given that patient ruled in, patient
was then transferred to [**Hospital1 18**] for further evaluation and for
cardiac catheterization.
.
Of note patient also had mechanical fall down 4 stairs and had
struck head. Denied any LOC. Head CT at OSH was negative for
head bleed.
.
Prior to transfer, patient's SBPs ranged from 80s-100s. Patient
was given approximately 1.5L NS while at OSH. On arrival to
[**Hospital1 18**], patient was taken directly to cath lab where an echo was
performed showing hypokinesis of inferolateral wall with LVEF
50-55%. Cath showed RCA proximal thrombotic occlusion. PCI was
completed with 2.0x12mm BMS via radial approach.
.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: - Prempro daily
- Flovent MDI [**Hospital1 **]
- Citalopram 20mg daily
- Xanax 0.25mg Daily
- Zocor

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: VS: 96.2, 79, 81/48, 22 and 98% on 3L
GENERAL: NAD. AAOx3. Appears tired and complains of cold hands.

FAMILY HISTORY: M: deceased at age in 60s from MI. Cannot recall when first MI
was
F: alive at 95. Had "open heart surgery" in [**2147**].

SOCIAL HISTORY: Patient is a country line dancer instructor. Currently resides
with husband
-[**Name (NI) 1139**] history: Smoked 1ppd x 39years. Quit in [**2147**].
-ETOH: none
-Illicit drugs: none
.
Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Dysthymic disorder
Subendo infarct, initial,Crnry athrscl natve vssl,Mitral valve disorder,Hypertension NOS,Hyperlipidemia NEC/NOS,Osteoporosis NOS,Chr airway obstruct NEC,Esophageal reflux,Dysthymic disorder
Admission Date:  [**2158-12-11**]              Discharge Date:   [**2158-12-14**]

Date of Birth:  [**2092-1-23**]             Sex:   F

Service: MEDICINE

Allergies:
Erythromycin Base

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
SOB and epigastric burning

Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to the right
coronary artery.


History of Present Illness:
This is a 66 y/o F with h/o HTN and carotid disease s/p R CEA
(in [**2155**]) who initially presented to OSH with shortness of
breath and epigastric burning. This started while patient was
vomiting (non-bilious/non-bloody) and worsened when she walked
around home. Stated that nausea/vomiting/epigastric pain had
been presented with "few days" prior to admission. On day of
presentation, pain was worsening, so she decided to come into
hosptial.
.
At OSH, patient was given "GI cocktail," aspirin 162mg, zofran,
protonix, and morphine 2mg with adequate relief of pain. Per
report from OSH, EKG had Q waves in inferior leads and ST
depressions in V3-V6. Trop were noted be 5.89 followed by 13.47.
Was then started on heparin gtt. Patient continued to have chest
discomfort and was started on nitro paste. Of note patient also
received plavix 300mg x 1. Given that patient ruled in, patient
was then transferred to [**Hospital1 18**] for further evaluation and for
cardiac catheterization.
.
Of note patient also had mechanical fall down 4 stairs and had
struck head. Denied any LOC. Head CT at OSH was negative for
head bleed.
.
Prior to transfer, patient's SBPs ranged from 80s-100s. Patient
was given approximately 1.5L NS while at OSH. On arrival to
[**Hospital1 18**], patient was taken directly to cath lab where an echo was
performed showing hypokinesis of inferolateral wall with LVEF
50-55%. Cath showed RCA proximal thrombotic occlusion. PCI was
completed with 2.0x12mm BMS via radial approach.
.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- Carotid disease s/p Right CEA in [**2155**]
- GERD
- s/p eye surgery
- Osteoporosis
- COPD
- Anxiety

Social History:
Patient is a country line dancer instructor. Currently resides
with husband
-[**Name (NI) 1139**] history: Smoked 1ppd x 39years. Quit in [**2147**].
-ETOH: none
-Illicit drugs: none
.

Family History:
M: deceased at age in 60s from MI. Cannot recall when first MI
was
F: alive at 95. Had "open heart surgery" in [**2147**].

Physical Exam:
VS: 96.2, 79, 81/48, 22 and 98% on 3L
GENERAL: NAD. AAOx3. Appears tired and complains of cold hands.

HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MM. No
xanthalesma.
NECK: Supple. No JVD appreciated. No carotid bruits auscultated.

CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities. Resp were shallow, without
accessory muscle use. B/L crackles to mid-lungs; no wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No
rebounding/guarding. No HSM. No abdominial bruits.
EXTREMITIES: Upper extremities cool. Lower extremities warmer.
No skin turgor. No c/c/e. No femoral bruits. Cath site at radial
artery clean.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
[**2158-12-14**] 06:35AM BLOOD WBC-6.8 RBC-3.69* Hgb-11.8* Hct-33.6*
MCV-91 MCH-32.0 MCHC-35.2* RDW-13.4 Plt Ct-174
[**2158-12-11**] 04:59PM BLOOD WBC-10.7 RBC-3.74* Hgb-11.8* Hct-34.8*
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.3 Plt Ct-172
[**2158-12-11**] 04:59PM BLOOD Neuts-82.4* Lymphs-13.2* Monos-4.0
Eos-0.1 Baso-0.4
[**2158-12-14**] 06:35AM BLOOD Plt Ct-174
[**2158-12-11**] 04:59PM BLOOD PT-12.0 PTT-35.7* INR(PT)-1.0
[**2158-12-14**] 06:35AM BLOOD Glucose-120* UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-100 HCO3-32 AnGap-9
[**2158-12-13**] 06:10AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-138
K-3.9 Cl-103 HCO3-33* AnGap-6*
[**2158-12-12**] 05:58AM BLOOD Glucose-87 UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-110* HCO3-22 AnGap-9
[**2158-12-11**] 04:59PM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-136
K-4.2 Cl-107 HCO3-21* AnGap-12
[**2158-12-12**] 05:58AM BLOOD CK(CPK)-775*
[**2158-12-11**] 11:45PM BLOOD CK(CPK)-1086*
[**2158-12-11**] 11:45PM BLOOD CK-MB-90* MB Indx-8.3* cTropnT-1.84*
[**2158-12-14**] 06:35AM BLOOD Phos-2.9 Mg-1.9
[**2158-12-11**] 04:59PM BLOOD Calcium-7.8* Phos-2.2* Mg-2.0
[**2158-12-11**] 05:38PM BLOOD Lactate-1.9
.
ECG: [**2158-12-11**]: Sinus rhythm. Low limb lead voltage.
Non-diagnostic Q waves in the inferior leads with mild ST
segment elevation. There is mild ST segment depression in leads
I and aVL as well as in the precordial leads. An RSR' pattern is
present in leads V1-V2. No previous tracing available for
comparison. Clinical correlation is suggested.
.

ECG: [**2158-12-11**]: Sinus rhythm. Since the previous tracing ST-T
wave abnormalities may be less prominent. Precordial voltage is
somewhat diminished. Clinical correlation is suggested.
.
ECG: [**2158-12-11**]: Sinus rhythm. Since the previous tracing of
[**2158-12-11**] no significant change in previously noted findings
.
ECG: [**2158-12-12**] Sinus rhythm. Since the previous tracing of
[**2158-12-11**] inferior ST segment elevation is less prominent. ST
segment depression in leads I and aVL is less prominent.
Otherwise, no change.
.
Echo [**2158-12-11**]: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thicknesses and cavity size
are normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal inferior and
inferolateral walls and mid inferior wall. The remaining
segments contract normally (LVEF = 50-55%). Right ventricular
chamber size is normal with hypokinesis of the basal free wall.
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction and basal right ventricular free wall
hypokinesis c/w CAD (proximal RCA distribution). Moderate mitral
regugitation most likely due to papillary muscle dysfunction.
.
CLINICAL IMPLICATIONS:
Based on [**2154**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Chest PA and Lateral [**2158-12-12**]
IMPRESSION: Absence of marked cardiac enlargement but upper zone

redistribution, interstitial basal emphysema and moderate amount
of bilateral pleural effusion consistent with CHF of moderate
duration. Nonsignificant enlargement of the heart silhouette is
not unusual in acute MIs. On the obtained AP and lateral view,
no significant intracardiac calcifications can be identified. No
previous chest examination exists in our records.


Brief Hospital Course:
This is a 60 year lady with history of HTN, carotid disease
status post right CEA initially presenting with dypsnea and
epigastric pain and was found to have an NSTEMI and is status
post cathtereization and placement of a bare metal stent to the
right coronary artery.
.
# CORONARIES:  Ruled in for NSTEMI / MI with elevated troponin
and involvement of right heart at an outside hospital. The
patient received plavix prior to transfer. Emergent
catheterization demonstated RCA proximal thrombotic occlusion
with PCI with 2.0x12mm bare metal stent via right radial
approach. She was started on aspirin, plavix, a statin and
integrillin.  Metoprolol initially held given hypotension and
started prior to discharge.  An ace-inhibitor should be started
in the outpatient setting when her pressures can support it.
- Start Ace-inhibitor in outpatient setting.
.
# PUMP / Hypotension: Prior to transfer she was hypotensive with
systolic blood pressures in 80s. Echo prior to procedure showing
LVEF of 50-55% and hypokinesis of inferolateral wall. She is
likely preload dependent with a dysfunctional RV and required
initial 2 liter fluid resuscitation and was on a dopamin gtt for
less than 24 hours.
.
# GERD: Switched to ranitidine daily, to avoid PPI/clopidogrel
interaction.
.
# COPD: Continued flovent
.
# Osteoporosis: Started Calcium and vitamin D
.
# Depression/Anxiety: Continued citalopram and ativan


Medications on Admission:
- Prempro daily
- Flovent MDI [**Hospital1 **]
- Citalopram 20mg daily
- Xanax 0.25mg Daily
- Zocor

Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Mitral Regurgitation
Hypertension
Chronic Obstructive Pulmonary disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You had a heart attack and received a bare metal stent to your
right coronary artery. Your heart function is close to normal
but we noticed that you have a leaky mitral valve that could
have been caused by the heart attack. You will get another
echocardiogram when you see Dr. [**Last Name (STitle) 5310**] and this echo should
show improvement of your heart function and the leaky valve. You
should follow the instructions of physical therapy for your
activity until you see Dr. [**Last Name (STitle) 5310**].

It is important that your high blood pressure is controlled and
you eat a heart healthy diet.
.
We made the following changes in you medicines:
1. Stop taking Prempro, this increases your risk of a heart
attack
2. Change the zocor to Atorvastatin (Lipitor) at a high dose to
control your cholesterol
3. Take aspirin and Plavix to prevent the stent from clotting
off. You will need to take this every day or you risk another
heart attack. Do not stop taking this medicine unless Dr.
[**Last Name (STitle) 5310**] says it is OK.
4. Start taking ranitidine to prevent stomach irritation
5. We started Metoprolol just prior to discharge and you
tolerated in well.

Followup Instructions:
Name: [**Last Name (LF) 88266**], [**First Name3 (LF) 1022**], P.A.
Location: PMG PHYSICIAN ASSOCIATES
Address: [**Location (un) 88267**] [**Apartment Address(1) 40744**], [**Location (un) **],[**Numeric Identifier 88268**]
Phone: [**Telephone/Fax (1) 36604**]
When: Wednesday, [**12-20**], 11AM

Name: [**Last Name (LF) 5310**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ CARDIOLOGY
Address: [**Doctor Last Name 37166**],LOWER LEVEL, [**Location (un) **],[**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 5315**]
When: Wednesday, [**12-27**], 10AM
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Dysthymic disorder'}


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: SOB and epigastric burning

PRESENT ILLNESS: This is a 66 y/o F with h/o HTN and carotid disease s/p R CEA
(in [**2155**]) who initially presented to OSH with shortness of
breath and epigastric burning. This started while patient was
vomiting (non-bilious/non-bloody) and worsened when she walked
around home. Stated that nausea/vomiting/epigastric pain had
been presented with "few days" prior to admission. On day of
presentation, pain was worsening, so she decided to come into
hosptial.
.
At OSH, patient was given "GI cocktail," aspirin 162mg, zofran,
protonix, and morphine 2mg with adequate relief of pain. Per
report from OSH, EKG had Q waves in inferior leads and ST
depressions in V3-V6. Trop were noted be 5.89 followed by 13.47.
Was then started on heparin gtt. Patient continued to have chest
discomfort and was started on nitro paste. Of note patient also
received plavix 300mg x 1. Given that patient ruled in, patient
was then transferred to [**Hospital1 18**] for further evaluation and for
cardiac catheterization.
.
Of note patient also had mechanical fall down 4 stairs and had
struck head. Denied any LOC. Head CT at OSH was negative for
head bleed.
.
Prior to transfer, patient's SBPs ranged from 80s-100s. Patient
was given approximately 1.5L NS while at OSH. On arrival to
[**Hospital1 18**], patient was taken directly to cath lab where an echo was
performed showing hypokinesis of inferolateral wall with LVEF
50-55%. Cath showed RCA proximal thrombotic occlusion. PCI was
completed with 2.0x12mm BMS via radial approach.
.
On review of systems, she 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. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: - Prempro daily
- Flovent MDI [**Hospital1 **]
- Citalopram 20mg daily
- Xanax 0.25mg Daily
- Zocor

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: VS: 96.2, 79, 81/48, 22 and 98% on 3L
GENERAL: NAD. AAOx3. Appears tired and complains of cold hands.

FAMILY HISTORY: M: deceased at age in 60s from MI. Cannot recall when first MI
was
F: alive at 95. Had "open heart surgery" in [**2147**].

SOCIAL HISTORY: Patient is a country line dancer instructor. Currently resides
with husband
-[**Name (NI) 1139**] history: Smoked 1ppd x 39years. Quit in [**2147**].
-ETOH: none
-Illicit drugs: none
. 

### Response:
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Osteoporosis, unspecified,Chronic airway obstruction, not elsewhere classified,Esophageal reflux,Dysthymic disorder'}
