CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: Mr. [**Known lastname 44755**] is a 73 year old man transfered from an outside
hospital with chest pain and ecg changes.

MEDICAL HISTORY: 1. ESRD on HD for 5 years
2. diverticulosis
3. GI bleed
4. PAF
5. CVA 2 years ago, with residual left sided weakness
6. CAD s/p MI (echo [**5-19**] with inferior hypokinesis)
7. Anemia
8. Cardiac arrest
9. GERD
10. OSA on CPAP 16 cm with 1 L oxygen
11. Moderate Aortic stenosis (echo in [**Month (only) 547**] at OSH)

MEDICATION ON ADMISSION: Amiodarone 200 mg po daily
Lipitor 10 mg po daily
Aspirin 81 mg daily
Celexa 20 mg daily
Levoxyl 25 micrograms daily
Prevacid 30 mg daily
Provigil 100 mg daily
Nephrocaps 1 cap daily
Coumadin 2.5 mg daily
Lorazepam 0.5 mg q 8 hr prn
Vancomycin 250 mg po three times a day
colace 100 mg po daily
xopenex q 6 hr
atrovent q 6 hr
epogen 12,000 unit sq M,W, F
lactinex 2 tab po bid
megace 800 mg daily

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: T 98.0 HR 110 BP 138/59 RR 24 O2 sat 99% on 4L
Gen: elderly gentleman, appearing older than stated age, lying
in bed, in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MM dry.
Neck: No JVD, no LAD.
Lungs: coarse BS bilaterally, anteriorly and posteriorly.
Expriatory wheezes.
CV: Regular with no MRG appreciated.
Abd: soft, distended, tender in the RUQ with guarding, no
rebound. active bowel sounds.
Ext: no clubbing, cyanosis or edema. Weak pulses bilaterally.
Neuro: sleepy but arousable. Follows commands. oriented to self,
place, but states date is [**2012**]. Strength 5/5 on the right and
4+/5 on the left lower extremity (can resist minor force) and
[**6-15**] on the right upper extremity and [**5-16**] on the left upper
extremity (cannot resist any force). Reflexes are 2+ in the left
patella and bicepts and 1+ on the right. Toes downgoing on right
and equivocal on left.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives at home with his wife. Stopped smoking in [**2105**].
Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Other specified forms of chronic ischemic heart disease,Foreign body in larynx,Acute bronchitis,Unspecified acquired hypothyroidism,Anemia, unspecified
Subendo infarct, initial,Food/vomit pneumonitis,Atrial fibrillation,CHF NOS,Acute respiratry failure,Septicemia NOS,Severe sepsis,Septic shock,Pleural effusion NOS,Int inf clstrdium dfcile,Chr ischemic hrt dis NEC,Foreign body in larynx,Acute bronchitis,Hypothyroidism NOS,Anemia NOS
Admission Date:  [**2113-7-23**]              Discharge Date:   [**2113-8-23**]

Date of Birth:  [**2040-6-19**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine; Iodine Containing

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Thoracentesis.
Thallium myocardial viability study.
Intubation.
Central line placement.
Echocardiogram.


History of Present Illness:
Mr. [**Known lastname 44755**] is a 73 year old man transfered from an outside
hospital with chest pain and ecg changes.

Patient has past medical history of ESRD on HD for 5 years, PAF,
CVA, anemia, CAD s/p MI, Aortic stenosis. Patient was admitted
to [**Hospital3 4107**] last month with an MI. His hospital course
was complicated by bradycardic arrest, MRSA pneumonia, C diff
colitis. He was discharged to NESH 3.5 weeks ago. Since this
admission he has had worsening mental status with dementia.

On the day of admission he complained of chest pain [**9-20**]
radiating to his right shoulder. This was relieved only after 3
NTG. BP was stable; HR was 105-113 during this episode. He was
transfered to [**Hospital3 417**] Hospital where ECG showed
intermittant rate related RBBB and LVH with strain. Patient was
pain free on arrival and remained pain free. He was given one
aspirin. TnI was 0.2 and the patient was transfered here for
management of ACS.

On arrival here the patient had 10/10 chest pain. ECG showed
sinus tachycardia with LVH and strain. Pain resolved with one
sublingual nitroglycerin. TnT here 0.6, and CK is 51.

Currently the patient denies chest pain, shortness of breath,
abdominal pain, nausea, vomiting. He reports frequent diarrhea.
He has h/o orthopnea, PND but denies pedal edema. He has SOB
with ambulation.

Past Medical History:
1. ESRD on HD for 5 years
2. diverticulosis
3. GI bleed
4. PAF
5. CVA 2 years ago, with residual left sided weakness
6. CAD s/p MI (echo [**5-19**] with inferior hypokinesis)
7. Anemia
8. Cardiac arrest
9. GERD
10. OSA on CPAP 16 cm with 1 L oxygen
11. Moderate Aortic stenosis (echo in [**Month (only) 547**] at OSH)

Social History:
Lives at home with his wife. Stopped smoking in [**2105**].

Family History:
non contributory

Physical Exam:
T 98.0 HR 110 BP 138/59 RR 24 O2 sat 99% on 4L
Gen: elderly gentleman, appearing older than stated age, lying
in bed, in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MM dry.
Neck: No JVD, no LAD.
Lungs: coarse BS bilaterally, anteriorly and posteriorly.
Expriatory wheezes.
CV: Regular with no MRG appreciated.
Abd: soft, distended, tender in the RUQ with guarding, no
rebound. active bowel sounds.
Ext: no clubbing, cyanosis or edema. Weak pulses bilaterally.
Neuro: sleepy but arousable. Follows commands. oriented to self,
place, but states date is [**2012**]. Strength 5/5 on the right and
4+/5 on the left lower extremity (can resist minor force) and
[**6-15**] on the right upper extremity and [**5-16**] on the left upper
extremity (cannot resist any force). Reflexes are 2+ in the left
patella and bicepts and 1+ on the right. Toes downgoing on right
and equivocal on left.


Pertinent Results:
OSH: 18.7\    /593   [**Age over 90 **]|95|25 /108   CK 30 MB 2.5 TnI 0.2 BNP >
5000
         /40.3\      5.3|30|5.9\

INR 2.5 DDimer 1409

LABS HERE:

[**Age over 90 **] |93|32 / 99    AGap=23
4.9 |26|6.4\

8:30p   CK: 38  MB: Notdone  Trop-*T*: 0.63
7:45p   CK: 51  MB: Notdone  Trop-*T*: 0.62

Ca: 10.0 Mg: 2.2 P: 3.7

ALT: 16 AP: 93 Tbili: 0.6 Alb:
AST: 22 LDH: 172 Dbili:  TProt:
[**Doctor First Name **]: 54 Lip: 46
TSH:Pnd

                  MCV 92
17.7\12.1/569
    /37.8\
 N:87.5 Band:0 L:8.7 M:2.5 E:0.8 Bas:0.5
Hypochr: 1+ Anisocy: 1+ Polychr: 1+
Plt-Est: High

PT: 20.9  PTT: 28.5  INR: 2.9

ECG: 8:20 Sinus tachycardia at 107 bpm, LAD, RBBB, Q in III,
AVF. TWI in V1-V4, III, AVF. No STE or depression.

14:09 Sinus at 95 bpm. First degree AV block. LAD. Q in III,
AVF. Flat TW in I, AVL, V5-6. LVH with strain pattern.

14:20 Sinus at 96 bpm. First degree AV block. LAD. Q in III,
AVF. TW flat in I, avl, V5-6. LVH with strain pattern.

18:47 Sinus at 106 bpm. RBBB. LAD. TW normalization in I, AVL,
V5-6. Q in III, AVF. TWI in V1-V4. No STE or depression.

19:39 Sinus at 104 bpm. LAD. TW flat in I, AVL, V5-6. Q in III,
AVF. LVH with strain pattern.

labs around time of GI bleed.
[**2113-8-17**] 01:25PM BLOOD PT-14.2* PTT-36.6* INR(PT)-1.3
[**2113-8-17**] 08:07PM BLOOD PT-15.4* PTT-80.0* INR(PT)-1.6
[**2113-8-18**] 04:32AM BLOOD PT-14.5* PTT-63.0* INR(PT)-1.4

labs on discharge
[**2113-8-23**] 06:12AM BLOOD PT-21.0* PTT-33.7 INR(PT)-2.9
[**2113-8-23**] 06:12AM BLOOD WBC-10.0 RBC-3.44* Hgb-10.2* Hct-32.5*
MCV-94 MCH-29.7 MCHC-31.5 RDW-20.7* Plt Ct-335
[**2113-8-23**] 06:12AM BLOOD Glucose-79 UreaN-23* Creat-4.5*# Na-145
K-3.6 Cl-105 HCO3-28 AnGap-16
[**2113-8-23**] 06:12AM BLOOD Calcium-9.5 Phos-3.8 Mg-1.7

Brief Hospital Course:
This 73 year old gentleman with a history of ESRD on HD,
ischemic cardiomyopathy, EF 35%, PAF, h/o CVA, h/o CAD s/p MI
who was initially transferred here from [**Hospital3 4107**] on
[**2113-7-23**] with chest pain, intermittent RBBB/LVH, TropI 0.6, CK
51. [**Hospital3 **] course notable for bradycardic arrest, MRSA
pna, C diff colitis and was d/c to rehab. with MRSA pneumonia, C
diff colitis.
.
On admission here, pt thought not to have acute ischemia;
finished course of PO vanco for c diff and IV vanco for MRSA
pna. His mental status was noted to be poor, thought to be [**3-15**]
delerium. Dialysis was continued. Wished for CTA to r/o PE, but
pt has iodine allergy. Had abnl cxr so v/q not pursued either.
Passed swallow study on [**7-25**] and [**7-31**].
.
[**7-25**], pt had resp distress but cxr showed layering pleural
effusions L>R, BNP [**Numeric Identifier 44756**].
.
[**7-26**], patient had another episode of tachypnea, hypoxia at HD
and was transferred to the [**Hospital Unit Name 153**] for further mngt. In [**Hospital Unit Name 153**], he
was rapidly weaned to nasal cannula, CPAP at night (has OSA).
SOB thought to be multifactorial from volume overload, pleural
effusions, AF w/ RVR. Leukocytosis to 13-14 persisted but ID
work up negative besides his previous known infections, as
above. Effusion not tapped since patient's resp status improved
(he also apparently refused per record).
.
[**7-29**] Recurrence of tachypnea, tachycardia, hypotension on [**7-29**]
that was thought [**3-15**] aspiration vs flash pulm edema vs mucous
plugging, again improved w/o intervention. Aggressive chest PT
was initiated. Cards consulted who wished to optimize his CHF
mngt w/ Ace-i, cont amio/bb and stop digoxin. EF now 25% with
new akinesis.  Cardiac cath considered for concern of recurring
ischemia (INR elevated [**3-15**] coumadin, so held off for some time).
Vanco was started on [**8-1**] for GPC's in sputum and increased
secretions.
.
[**8-1**] With clinical improvement was transferred to general
medicine [**Hospital1 **]. Cath tentatively planned for [**8-7**], pt started on
heparin today for stroke ppx since INR now.

[**2113-8-5**] Had HD session w/o incident and had acute onset of resp
distress w/ sats 83% approx 30 min after arrival on floor. MICU
team near by and helped evaluate patient. VS at that time were T
96.3 BP 108/60's HR 90's RR 30's sats 83% NRB (was 98% 2L
previous to this). Pt confused but semi-alert, not mentating,
not comuunicative. ABG 7.42/40/49 on NRB. Code blue called for
impending resp arrest. pt w/ pulse; ekg NSR 90's old TWI's in
V1-V5. Intubated and brought to MICU.
.
MICU stay Underwent throacentesis with 1700 cc of serous fluid
removed which was transudative. He was thought to have flash
pulmonary edema. He was initially on a levophed gtt for
hypotension, but with fluid boluses he was weaned off the gtt.
[**8-7**]
-weaned off all pressors,
-seen by cardiology and they decided to defer catherization
until the patient was stable from a respiratory standpoint.
-Patient's stool was positive for C diff. He was started on
Flagyl for a ten day course. He was also
-started on levofloxacin/flagyl for empiric treatment of
aspiration pneumonia.
[**8-8**].
-extubated, transferred to general medicine wards
.
General medicine [**Hospital1 **] stay.
[**Date range (1) 44757**]
This period was characterized by recurrent episodes of chest
pain, respiratory distress, hypotension, and tachycardia.  No
EKG changes accompanied these. Aggressive suctioning with O2
therapy successfully resolved all of these episodes, and it was
felt these episodes were secondary to mucus plugging.  Chest PT,
nebulizer therapy, and mucolytic therapy were instituted with
success.
.
[**8-16**] Episode of 200 cc coffee ground emesis after HD.  Emesis
guiaiac positive, stool guaiac negative.  PTT was
supratherapeutic GI consulted, felt endoscopy would not be of
benefit unless catheterization performed.
.
[**8-17**] Thallium viability performed revealed no reversible defects,
as no tissue could be recovered by reperfusion, Cardiology
decided catheterization would not benefit the patient and signed
off.  Per there recommendations, beta blocker and ACEi therapy
were titrated up.  GI signed off.

[**8-18**] Thoracentesis performed 2L removed transudative negative for
gram stain and culture, largely for respiratory comfort.
Respiratory function notably improved after this, with somewhat
less oxygen requirement, and more vigorous cough reflex.  Lungs
clear to auscultation.  Pt had only one minor episode of
respiratory distress after this time.

[**8-21**] Wife met with attending, Dr. [**Last Name (STitle) **], and elected to change
pt status to DNR/DNI.

In summary this is a 73 year old Caucasian gentleman with a
prior history of coronary artery disease s/p myocardial
infarction, paroxysmal atrial fibrillation on amiodarone and
anticoagulation, ischemic cardiomyopathy EF 25%, end stage renal
disease on hemodialysis.  He was admitted for non-ST elevation
MI, since admission his course has been complicated by recurrent
respiratory distress with chest pain and hypotension and
necessitating one intubation, pneumonia, upper GI bleed from
supratherapeutic INR, and C. dificile
on discharge this patients issues are as follows.

Resp distress:  Improved s/p thoracentesis and with nebulizer,
chest PT and mucinex therapy.  Mucus plugging was likely cause
of his recurrent resp distress.   No recent sign of pneumonia.
Prior episode of pneumonia during stay successfully treated with
levofloxacin.  No EKG changes have occured during these
episodes.

Ischemic heart disease:  EF of 25%, now with new akinesis.
Unfortunately, invasive procedures will no longer benefit the pt
owing to the lack of viable tissue left.  We have attempted to
optimize medical management using beta blocker and ace inhibitor
for protection of remainder of myocardium.

PAF:  Appears stable, on amiodarone and now transitioned to
Coumadin for anticoagulative therapy last INR: 2.9.

End Stage Renal Disease:   On hemodialysis Tuesday, Thursday,
and Saturday.  On epogen for anemia.  Appreciate work of renal
team in managing fluids.

Sepsis:  Pt was septic requiring pressors x 3, resolved in MICU.
h/o MRSA pneumonia.

GI bleed:  No further episodes of GI bleed since [**8-16**]; this was
probably secondary to his supratherapeutic INR

C. Dificile:  On discharge, he will be on day 10 of 14

DVT prophylaxis: Coumadin

Anemia: Likely from chronic disease, ESRD, on epogen.

Hypothyroid: On replacement.

Code: DNR/DNI per wife as of [**2113-8-21**]


Medications on Admission:
Amiodarone 200 mg po daily
Lipitor 10 mg po daily
Aspirin 81 mg daily
Celexa 20 mg daily
Levoxyl 25 micrograms daily
Prevacid 30 mg daily
Provigil 100 mg daily
Nephrocaps 1 cap daily
Coumadin 2.5 mg daily
Lorazepam 0.5 mg q 8 hr prn
Vancomycin 250 mg po three times a day
colace 100 mg po daily
xopenex q 6 hr
atrovent q 6 hr
epogen 12,000 unit sq M,W, F
lactinex 2 tab po bid
megace 800 mg daily


Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Solution
Injection ASDIR (AS DIRECTED).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Oral Thrush.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Course to complete 2 weeks of
therapy on [**2113-8-27**].
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
16. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): Please do NOT give on hemodialysis days.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
18. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Please do NOT give on hemodialysis days.
20. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
21. Warfarin Sodium 1 mg Tablet Sig: 1.5 Tablets PO at bedtime.

22. Compazine 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]

Discharge Diagnosis:
Non-ST elevated MI
Sepsis with hypotension.
End stage renal disease now on hemodialysis.
Congestive heart failure (ischemic cardiomyopathy.
Coronary artery disease.
Clostridium difficile infection.
Recurrent respiratory distress with mucus plugging.
Gastrointestinal bleed.
Paroxysmal atrial fibrillation.
Anticoagulative therapy

Discharge Condition:
Stable.
Stable.Still requiring oxygen 2-3 L by NC or face mask.Chest
pain free.

Discharge Instructions:
Please return to hospital if respiratory distress, chest pain
recurs.  Please return if coffee ground or bloody vomiting
recur.


Followup Instructions:
Rehabilitation facility.
Please see PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] in [**8-20**] days.
{'Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Other specified forms of chronic ischemic heart disease,Foreign body in larynx,Acute bronchitis,Unspecified acquired hypothyroidism,Anemia, unspecified'}


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: Mr. [**Known lastname 44755**] is a 73 year old man transfered from an outside
hospital with chest pain and ecg changes.

MEDICAL HISTORY: 1. ESRD on HD for 5 years
2. diverticulosis
3. GI bleed
4. PAF
5. CVA 2 years ago, with residual left sided weakness
6. CAD s/p MI (echo [**5-19**] with inferior hypokinesis)
7. Anemia
8. Cardiac arrest
9. GERD
10. OSA on CPAP 16 cm with 1 L oxygen
11. Moderate Aortic stenosis (echo in [**Month (only) 547**] at OSH)

MEDICATION ON ADMISSION: Amiodarone 200 mg po daily
Lipitor 10 mg po daily
Aspirin 81 mg daily
Celexa 20 mg daily
Levoxyl 25 micrograms daily
Prevacid 30 mg daily
Provigil 100 mg daily
Nephrocaps 1 cap daily
Coumadin 2.5 mg daily
Lorazepam 0.5 mg q 8 hr prn
Vancomycin 250 mg po three times a day
colace 100 mg po daily
xopenex q 6 hr
atrovent q 6 hr
epogen 12,000 unit sq M,W, F
lactinex 2 tab po bid
megace 800 mg daily

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: T 98.0 HR 110 BP 138/59 RR 24 O2 sat 99% on 4L
Gen: elderly gentleman, appearing older than stated age, lying
in bed, in NAD.
HEENT: PERRL, EOMI, sclera anicteric, MM dry.
Neck: No JVD, no LAD.
Lungs: coarse BS bilaterally, anteriorly and posteriorly.
Expriatory wheezes.
CV: Regular with no MRG appreciated.
Abd: soft, distended, tender in the RUQ with guarding, no
rebound. active bowel sounds.
Ext: no clubbing, cyanosis or edema. Weak pulses bilaterally.
Neuro: sleepy but arousable. Follows commands. oriented to self,
place, but states date is [**2012**]. Strength 5/5 on the right and
4+/5 on the left lower extremity (can resist minor force) and
[**6-15**] on the right upper extremity and [**5-16**] on the left upper
extremity (cannot resist any force). Reflexes are 2+ in the left
patella and bicepts and 1+ on the right. Toes downgoing on right
and equivocal on left.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives at home with his wife. Stopped smoking in [**2105**]. 

### Response:
{'Subendocardial infarction, initial episode of care,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Other specified forms of chronic ischemic heart disease,Foreign body in larynx,Acute bronchitis,Unspecified acquired hypothyroidism,Anemia, unspecified'}
