CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: Mr. [**Known lastname **] is a 47yo male with past medical history of htn, hld
and family history of CABG in his brother at age 38, who was
found to have STEMI and is s/p LHC with intervention. The
patient reports that he had had about 2 weeks of chest pain,
which had been right sided and associated with right arm
tingling. There was associated nausea. He had no associated
dyspnea. He reports that he did note chest pain in his sternum
once when he was running. He is able to walk up flights of
stairs, limited by knee pain not SOB. He does endorse a dry
cough, which has started since he began lisinopril (now
discontinued).
.
His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], got biomarkers and found his troponin to
be elevated to 0.66. Dr. [**Last Name (STitle) **] called Mr. [**Known lastname **] to advise that
he report to the [**Hospital1 18**] ED. En route to the ED, the patient did
experiencing acute chest pain, he received nitro which brought
the pain to a [**2-20**] but ongoing chest pressure. In the ED, his
EKG revealed STE in V2-V4 and Q's in III, aVF and V2-V3. He was
loaded with Plavix 600mg, heparin bolus and aspirin. In the cath
lab, the patient was found to have:  LAD with 99% mid occlusion;
diffuse 60% mid to distal occlusions; LCX 90% major OM; RCA 80%
posterolateral. He received drug eluting stent of mid LAD with
2.75 x 28 Promus. Diffuse moderately severe disease in mid to
distal LAD was not dilated. He was hemodynamically stable
throughout the procedure.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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, syncope or presyncope.

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

MEDICATION ON ADMISSION: - propanolol 10mg TID (started [**1-10**], not yet started Rx)
- aspirin 81mg daily
- On [**1-10**], discontinued from lisopril 10mg PO daily and
simvastatin 20mg daily

ALLERGIES: lisinopril

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T=98.5 BP=147/100 HR=90 RR= 16 O2 sat= 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthalesma.
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, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+

FAMILY HISTORY: Mother: 68yo DM2 on insulin, HTN
Father: not involved, but had an AMI 10 yrs ago at age 60
Siblings: 1 brother with CABG at age 38. 1 sister - pt unaware
of
her health status
Children: 1 son, 18yo, healthy

SOCIAL HISTORY: Marital Status: single
Lives with: son
Employment: [**Hospital6 **] Hospital, public safety, 40 hrs/wk
Smoking hx: never
EtOH hx: 5 beers/week but last drink was in the summer.
Illicit drug use: former MJ, no other ILL, no IVDU
STDs: neg, last HIV test 2 yrs ago
Hails from: [**Male First Name (un) 1056**]
Acute myocardial infarction of anterolateral wall, initial episode of care,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Essential and other specified forms of tremor,Heart disease, unspecified
AMI anterolateral, init,Hyperlipidemia NEC/NOS,Hypertension NOS,Crnry athrscl natve vssl,Tremor NEC,Heart disease NOS
Admission Date:  [**2198-1-11**]              Discharge Date:   [**2198-1-16**]

Date of Birth:  [**2150-3-15**]             Sex:   M

Service: MEDICINE

Allergies:
lisinopril

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
[**2198-1-11**] - Left heart catheterization with drug eluting stent in
left anterior descending artery
[**2198-1-15**] - Left heart cath with drug eluting stent to an obtuse
marginal and posterolateral branch

History of Present Illness:
Mr. [**Known lastname **] is a 47yo male with past medical history of htn, hld
and family history of CABG in his brother at age 38, who was
found to have STEMI and is s/p LHC with intervention. The
patient reports that he had had about 2 weeks of chest pain,
which had been right sided and associated with right arm
tingling. There was associated nausea. He had no associated
dyspnea. He reports that he did note chest pain in his sternum
once when he was running. He is able to walk up flights of
stairs, limited by knee pain not SOB. He does endorse a dry
cough, which has started since he began lisinopril (now
discontinued).
.
His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], got biomarkers and found his troponin to
be elevated to 0.66. Dr. [**Last Name (STitle) **] called Mr. [**Known lastname **] to advise that
he report to the [**Hospital1 18**] ED. En route to the ED, the patient did
experiencing acute chest pain, he received nitro which brought
the pain to a [**2-20**] but ongoing chest pressure. In the ED, his
EKG revealed STE in V2-V4 and Q's in III, aVF and V2-V3. He was
loaded with Plavix 600mg, heparin bolus and aspirin. In the cath
lab, the patient was found to have:  LAD with 99% mid occlusion;
diffuse 60% mid to distal occlusions; LCX 90% major OM; RCA 80%
posterolateral. He received drug eluting stent of mid LAD with
2.75 x 28 Promus. Diffuse moderately severe disease in mid to
distal LAD was not dilated. He was hemodynamically stable
throughout the procedure.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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, syncope or presyncope.

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

2. CARDIAC HISTORY:
- CABG:  none
- PERCUTANEOUS CORONARY INTERVENTIONS:  [**2198-1-11**] LHC with DES in
LAD.
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- cervical dystonic tremor
- Appendectomy at age 44, hospitalized due to perioperative
complications at [**Hospital1 2025**] x 1 month.


Social History:
Marital Status: single
Lives with: son
Employment: [**Hospital6 **] Hospital, public safety, 40 hrs/wk
Smoking hx: never
EtOH hx: 5 beers/week but last drink was in the summer.
Illicit drug use: former MJ, no other ILL, no IVDU
STDs: neg, last HIV test 2 yrs ago
Hails from: [**Male First Name (un) 1056**]

Family History:
Mother: 68yo DM2 on insulin, HTN
Father: not involved, but had an AMI 10 yrs ago at age 60
Siblings: 1 brother with CABG at age 38. 1 sister - pt unaware
of
her health status
Children: 1 son, 18yo, healthy

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=98.5 BP=147/100 HR=90 RR= 16 O2 sat= 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthalesma.
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, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+

DISCHARGE PHYSICAL EXAM:
GENERAL: NAD. Oriented x 3. Mood, affect appropriate.
HEENT: no LAD or JVD
CARDIAC: RR, normal S1, S2. No murmur, rub or gallop. No
thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No cyanosis, clubbing or edema. No femoral bruits.
Right groin with mild ecchymosis and tenderness, no hematoma.
SKIN: No stasis dermatitis, ulcers.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

Pertinent Results:
ADMISSION LABS:

[**2198-1-11**] 09:00PM BLOOD WBC-7.6 RBC-5.06 Hgb-15.1 Hct-45.4 MCV-90
MCH-29.9 MCHC-33.3 RDW-12.9 Plt Ct-307
[**2198-1-11**] 09:00PM BLOOD Neuts-56.4 Lymphs-35.8 Monos-4.9 Eos-2.2
Baso-0.6
[**2198-1-11**] 09:00PM BLOOD PT-11.3 PTT-33.1 INR(PT)-1.0
[**2198-1-11**] 09:00PM BLOOD Plt Ct-307
[**2198-1-11**] 10:43AM BLOOD UreaN-18 Creat-0.9 Na-139 K-5.1 Cl-102
HCO3-30 AnGap-12
[**2198-1-11**] 09:00PM BLOOD Calcium-10.1 Phos-4.1

PERTINENT LABS AND STUDIES

[**2198-1-11**] 10:43AM BLOOD CK-MB-7 cTropnT-0.66*
[**2198-1-11**] 09:00PM BLOOD cTropnT-0.69*
[**2198-1-11**] 10:43AM BLOOD CK(CPK)-238

- ECG [**2198-1-11**]:  Qs in inferior leads; ST elevations in anterior
leads, rate 95.
.
- CXR [**2198-1-11**]: No acute cardiopulmonary process.
.
- C SPINE NON TRAUMA [**2198-1-11**]:  No acute abnormality.
.
- CARDIAC CATH [**2198-1-11**]: LAD with 99% mid occlusion; diffuse 60%
mid to distal occlusions; LCX 90% major OM; RCA 80%
posterolateral. He received drug eluting stent of mid LAD with
2.75 x 28 Promus. Diffuse moderately severe disease in mid to
distal LAD was not dilated.

-CARDIAC CATH [**2198-1-15**]: (full report not available at time of
discharge summary) - DES placed in OM branch of LCx as well as
in posterolateral branch

Discharge labs:
[**2198-1-16**] 07:25AM BLOOD WBC-6.9 RBC-5.27 Hgb-15.9 Hct-45.8 MCV-87
MCH-30.2 MCHC-34.8 RDW-13.4 Plt Ct-261
[**2198-1-16**] 07:25AM BLOOD Glucose-107* UreaN-11 Creat-0.9 Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
[**2198-1-16**] 07:25AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1

Brief Hospital Course:
47M with a PMH significant for HTN, HLD, tremor who presented
with STEMI s/p LHC and placement of proximal LAD (single drug
eluting Promus stent) noted to have three vessel disease; with
LCx and RHC involvement. S/P DES x2 on [**1-15**] to OM and RPL
.
# CAD:  Patient presented to [**Hospital1 18**] for management of STEMI.  The
patient was found to have three vessel disease on initial left
heart cath and had intervention on the LAD, which was thought to
be the culprit lesion.  He was started on ASA 325 mg PO daily
and initially received Prasugrel 10mg PO daily s/p load of
clopidogrel 600 mg PO x1 for dual antiplatlet therapy. Received
eptifibatide at 2 mcg/kg/min x 18 hours after the initial
cardiac cath. Immediately after the first LHC, he was noted to
have ongoing ST segment elevations.  Started on losartan for
afterload reduction (has cough to ACEi) and to decrease cardiac
work. Home propranolol was changed to metoprolol at discharge.
Plan to continue Plavix for 1 year for DES, also started on high
dose statin (atorvastatin 80mg).  A transthoracic echo performed
after the intial cardiac catheterization and showed evidence of
apical akinesis with an EF of 35%.  He was discharged on
warfarin to prevent thrombus formation.  As mentioned below, he
will need a repeat TTE in 6 weeks to evaluate whether he would
benefit from ICD placement.
.
# HTN: Patient with history of hypertension. At discharge, his
home antihypertensive regimen will be changed to metoprolol and
losartan as above.
.
CHRONIC CARE:
# HLD: lipids elevated in [**2197-9-11**], with LDL of 163 and total
cholesterol of 256. High dose atorvastatin at discharge because
he is s/p STEMI.
.
# Cervical dystonic tremor: the patient is following with
neurology and may proceed with Botulism injections to treat his
tremor in the outpatient setting.  His home propranolol (which
he took for tremor) has been stopped and changed to metoprolol
as above.
.
ISSUES OF TRANSITIONS IN CARE:
CODE:  full code (Confirmed)
COMM:  [**Name (NI) 2013**] [**Name (NI) 1071**], mother, [**Telephone/Fax (1) 88626**]
PENDING STUDIES:
ISSUES TO ADDRESS AT FOLLOW UP:
- Will need repeat echocardiogram in 1.5 months to evaluate
heart function, if the EF is depressed, patient should be
referred to EP for ICD placement. Repeat echo may also be
indicated in 3 months as well.
- Will need INR followed as an outpatient as he has been
discharged on Coumadin

Medications on Admission:
- propanolol 10mg TID (started [**1-10**], not yet started Rx)
- aspirin 81mg daily
- On [**1-10**], discontinued from lisopril 10mg PO daily and
simvastatin 20mg daily

Discharge Medications:
1. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*75 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
Please check INR, chem-7 and CBC on Friday [**1-19**] before
your appt with Dr. [**Last Name (STitle) **]


Discharge Disposition:
Home

Discharge Diagnosis:
primary: ST elevation myocardial infarction, hypertension
secondary: hyperlipidemia

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


Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted because you were found to have a heart attack.
Two  cardiac catherizations were done to clear blockages in your
heart arteries that caused the heart attack. You had some drug
eluting stents placed to keep these arteries open. You have been
started on aspirin and clopidogrel (PLavix) to prevent the
stents from clotting off and causing another heart attack. You
will need to take these medicines every day without fail, do not
miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking aspirin and plavix unless Dr. [**Last Name (STitle) **]
tells you it is OK. Your heart is weak after the heart attack
and you will need to avoid salt in your diet and watch for signs
of swelling or trouble breathing. Make sure to weigh yourself
every day in the morning before breakfast. Call Dr. [**Last Name (STitle) **] if your
weight increases more than 3 pounds in 1 day or 5 pounds in 3
days.
You were started on coumadin because of your weak heart. You
will need to take this every day and get your coumadin blood
level checked frequently. [**Doctor First Name **] from Dr.[**Name (NI) 84011**] office will
contact you about your coumadin dose.
.
Please note the following changes to your medications:
1. STOP taking lisinopril and propanolol
2. START taking clopidogrel (plavix) and aspirin every day to
keep the stents open
3. START taking atorvastatin (Lipitor) every day to lower your
cholesterol
4. START taking Metoprolol to lower your heart rate and help
your heart recover from the heart attack.
5. START taking losartan to lower your blood pressure and help
your heart recover from the heart attack.
6. START taking coumadin to prevent blood clots and a stroke.
You will need to get your INR checked on Friday [**1-19**] at Dr. [**Name (NI) 88627**] office. You have a prescription to take to the office.


You will need a repeat echocardiogram in 1.5months.

Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: [**1-19**] at 9:20am
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
***Please get your INR checked BEFORE Dr.[**Name (NI) 13892**] appt.
.
Department: [**Hospital1 18**] [**Location (un) 2352**]- ADULT MED
When: THURSDAY [**2198-2-1**] at 6:30 PM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Essential and other specified forms of tremor,Heart disease, 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: STEMI

PRESENT ILLNESS: Mr. [**Known lastname **] is a 47yo male with past medical history of htn, hld
and family history of CABG in his brother at age 38, who was
found to have STEMI and is s/p LHC with intervention. The
patient reports that he had had about 2 weeks of chest pain,
which had been right sided and associated with right arm
tingling. There was associated nausea. He had no associated
dyspnea. He reports that he did note chest pain in his sternum
once when he was running. He is able to walk up flights of
stairs, limited by knee pain not SOB. He does endorse a dry
cough, which has started since he began lisinopril (now
discontinued).
.
His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], got biomarkers and found his troponin to
be elevated to 0.66. Dr. [**Last Name (STitle) **] called Mr. [**Known lastname **] to advise that
he report to the [**Hospital1 18**] ED. En route to the ED, the patient did
experiencing acute chest pain, he received nitro which brought
the pain to a [**2-20**] but ongoing chest pressure. In the ED, his
EKG revealed STE in V2-V4 and Q's in III, aVF and V2-V3. He was
loaded with Plavix 600mg, heparin bolus and aspirin. In the cath
lab, the patient was found to have:  LAD with 99% mid occlusion;
diffuse 60% mid to distal occlusions; LCX 90% major OM; RCA 80%
posterolateral. He received drug eluting stent of mid LAD with
2.75 x 28 Promus. Diffuse moderately severe disease in mid to
distal LAD was not dilated. He was hemodynamically stable
throughout the procedure.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, 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, syncope or presyncope.

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

MEDICATION ON ADMISSION: - propanolol 10mg TID (started [**1-10**], not yet started Rx)
- aspirin 81mg daily
- On [**1-10**], discontinued from lisopril 10mg PO daily and
simvastatin 20mg daily

ALLERGIES: lisinopril

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T=98.5 BP=147/100 HR=90 RR= 16 O2 sat= 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink. No xanthalesma.
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, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
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+

FAMILY HISTORY: Mother: 68yo DM2 on insulin, HTN
Father: not involved, but had an AMI 10 yrs ago at age 60
Siblings: 1 brother with CABG at age 38. 1 sister - pt unaware
of
her health status
Children: 1 son, 18yo, healthy

SOCIAL HISTORY: Marital Status: single
Lives with: son
Employment: [**Hospital6 **] Hospital, public safety, 40 hrs/wk
Smoking hx: never
EtOH hx: 5 beers/week but last drink was in the summer.
Illicit drug use: former MJ, no other ILL, no IVDU
STDs: neg, last HIV test 2 yrs ago
Hails from: [**Male First Name (un) 1056**] 

### Response:
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Essential and other specified forms of tremor,Heart disease, unspecified'}
