CHIEF COMPLAINT: Chest Pain/STEMI

PRESENT ILLNESS: 66M with hx of DM, HTN, hyperlipidemia, s/p CVA with residual
left sided deficits, who presented to ED with chest pain and
found to have STEMI.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY:  no documented hx of CAD; pt states heart
was "looked at" in past in DR, denies previous cardiac
catheterization.
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- s/p CVA - [**2106**] with L sided residual deficits which have
improved
- hypertension
- diabetes- metformin, daily FS at home 120s-190s
- hyperlipidemia
- asthma
- s/p R hydrocelectomy and R hernia repair

MEDICATION ON ADMISSION: Amlodipine 10 mg daily - Holding
Plavix 75 mg daily - Continued
fluticasone nasal spray - Held
HCTZ 12.5 mg daily - Held
lorazepam 1 mg qHS - Continued
metformin SR 500 mg daily - Held
Toprol XL 50 mg daily - Changed
Pravastatin 20 mg qHS - Increased
Valsartan 320 mg daily - Changed
Terbinafine 1% cream once daily - Held
albuterol sulfate 90 mcg 2 puffs QID PRN - Continued

ALLERGIES: Ace Inhibitors / Atenolol

PHYSICAL EXAM: PHYSICAL EXAMINATION:
GENERAL: WDWN overweight male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Small amt blood in mouth, gums oozing.
NECK: Supple, veins not distended; JVP difficult to appreciate,
<10cm
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.
Neuro: WNL except L-sided facial droop.
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: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Brother had large MI in mid-50s, Mother
and Sister w/ DM2. otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Denies
-ETOH: occasional
-Illicit drugs: none
Subendocardial infarction, initial episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of native coronary artery
Subendo infarct, initial,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Crnry athrscl natve vssl
Admission Date:  [**2109-7-5**]              Discharge Date:   [**2109-7-8**]

Date of Birth:  [**2042-9-16**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors / Atenolol

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

Major Surgical or Invasive Procedure:
Cardiac catheterization with balloon angioplasty X several and
transient intracoronary TPA


History of Present Illness:
66M with hx of DM, HTN, hyperlipidemia, s/p CVA with residual
left sided deficits, who presented to ED with chest pain and
found to have STEMI.

Patient presented with left sided chest pain radiating to left
arm starting 8am on AM of presentation with associated vomiting
and fatigue without dyspnea, orthopnea, PND, diaphoresis. 11
hours after initiation of chest pain, patient presented to [**Hospital1 18**]
ED at 7pm in the evening.
.
In ED, initial vitals were HR 125, BP 176/96, RR16, 98% on RA.
ECG showed >2mm STE in III>II, AVF, and septal/lateral leads,
and STD in I, AVL. Right sided leads showed STE in V4R.
Significant labs include: CK: 431  MB: 24  MBI: 5.6  Trop-T:
0.14. Cr 0.9, Hct 38.9, INR 1.2.
.
Code STEMI called, received 300 PO plavix, heparin bolus,
integrillin bolus prior to cath, ASA, put on NC O2, and brought
emergently to cath lab at 7:22pm. Found to have large acute
occlusion of proximal RCA with significant clot burden, received
serial balloon angioplasty PTCA along RCA with export catheter
remocal of clot, transient intracoronary TPA (total of 12mg) for
possible downstream occlusion of distal vessels. During
procedure, also had episode of bradycardia and hypotension with
2:1 block, resolved with atropine 0.5 x 2, and fluids. After
intervention, had restoration of flow up to mid vessel down to
acute OM. Final angiography showed 50% stenosis in proximal
vessel, mild dz in mid vessel and total occlusion of distal RCA
with large thrombus. LV gram showed EF about 50% with akinesis
of RV wall and minimal MR. [**Name13 (STitle) **] with some minor bleeding in
mouth, heparin and integrillin gtts discontinued before transfer
to CCU after cath.
.
On arrival to CCU, patient was chest pain free, feeling hungry,
Vitals stable w/ HR96, BP118/80, RR17, O2sat 99% on 2L NC. Had 1
episode nausea w/ vomiting, which resolved w/ zofran. Repeat ECG
post-cath showed >75% resolution of ST changes. O/n continued
asa, Plavix, restarted metprolol, uptitrated statin, gave std 1L
fluids, monitored hemodynamics.
.
On review of systems, he denies any prior history 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. Occasional visual sx w/
episodes of hypoglycemia. 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:  no documented hx of CAD; pt states heart
was "looked at" in past in DR, denies previous cardiac
catheterization.
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- s/p CVA - [**2106**] with L sided residual deficits which have
improved
- hypertension
- diabetes- metformin, daily FS at home 120s-190s
- hyperlipidemia
- asthma
- s/p R hydrocelectomy and R hernia repair

Social History:
-Tobacco history: Denies
-ETOH: occasional
-Illicit drugs: none


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Brother had large MI in mid-50s, Mother
and Sister w/ DM2. otherwise non-contributory.


Physical Exam:
PHYSICAL EXAMINATION:
GENERAL: WDWN overweight male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Small amt blood in mouth, gums oozing.
NECK: Supple, veins not distended; JVP difficult to appreciate,
<10cm
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.
Neuro: WNL except L-sided facial droop.
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:
ADMISSION LABS:
.
[**2109-7-5**] 07:30PM BLOOD WBC-12.4*# RBC-4.34* Hgb-13.8* Hct-38.9*
MCV-90 MCH-31.9 MCHC-35.6* RDW-13.2 Plt Ct-231
[**2109-7-5**] 07:30PM BLOOD Neuts-89.9* Lymphs-6.9* Monos-2.7 Eos-0.2
Baso-0.2
[**2109-7-5**] 07:30PM BLOOD PT-13.6* PTT-117.1* INR(PT)-1.2*
[**2109-7-5**] 07:30PM BLOOD Plt Ct-231
[**2109-7-5**] 07:30PM BLOOD UreaN-10 Creat-0.9 Na-134 K-4.0 Cl-101
HCO3-18* AnGap-19
[**2109-7-5**] 07:30PM BLOOD CK(CPK)-431*
[**2109-7-5**] 07:30PM BLOOD CK-MB-24* MB Indx-5.6 cTropnT-0.14*
.
.
PERTINENT LABS/STUDIES:
.
.
Cardiac enzymes prior to cath: CK: 431  MB: 24  MBI: 5.6
Trop-T: 0.14.
[**2109-6-20**]: Prior labs: CK 346, HbA1c 7.1, chol 138 TG 64 HDL 38
LDL 87
.
EKG: Prior to cath: sinus tachy, w/ >2mm ST elevations in
III>II, aVF, reciprocal ST depressions in aVL, aVR, I. R-sided
leads showed ST elevation of V4R
ECG: Post cath: ST elevations remain in III>II, aVF, but w/ 75%
resolution. aVL> aVR, I marked improvement in ST depresisons. Q
waves in II.
ECG arrival CCU: Continued improvement of ST elevations and
depresisons.
.
CARDIAC CATH/HEMODYNAMICS: Selective coronary angiography of
this right-dominant system revealed single-vessel coronary
artery disease.  The LMCA, LAD, and LCX had no
angiographically-apparent flow-limiting stenoses.  The RCA was
totally occluded proximally with a substantial clot burden.
2.  Limited resting hemodynamics demonstrated mildly elevated
left
ventricular filling pressures with an LVEDP of 23 mmHg, with no
gradient seen across the aortic valve on left-heart pullback.
3.  Left ventriculography demonstrated inferior akinesis with an
overall preserved ejection fraction and no significant mitral
regurgitation.
.
.
DISCHARGE LABS:
.


Brief Hospital Course:
66M with history of diabetes, hypertension, hyperlipidemia, s/p
CVA who presented with chest pain found to have inferolateral
STEMI, taken for emergent cardiac cath found to have large RCA
thrombus s/p serial PTCA and intracoronary TPA.
.
# ST elevation Myocardial Infarction: Patient with multiple risk
factors for CAD including DM, hyperlipidemia, HTN, but no
documented h/o CAD. Patient sent emergently to cath lab when
found to have inferolateral STEMI in ED with suggestion of RV
ischemia by V4R after 11 hour delay from onset of chest pain.
Cath showed large RCA thrombus s/p serial PTCA and intracoronary
TPA. Final angiography showed 50% stenosis in proximal vessel,
mild dz in mid vessel and total occlusion of distal RCA with
large thrombus. LV gram showed EF about 50% with akinesis of RV
wall and minimal MR. Heparin and integrillin discontinued after
cath. Post cath ECG showed >75% resolution of ST changes.
Patient chest pain free, hemodynamically stable. Pt was started
on ASA 325 mg daily, Plavix 75 mg daily. Statin increased to 80
mg daily. Metoprolol restarted at 25mg [**Hospital1 **] and uptitrated. CE
trended down starting [**2109-7-6**] and TTE showed the following -
IMPRESSION: Mild focal LV akinesis/hypokinesis consistent with
CAD (RCA territory). No significant valvular abnormality seen.
Dilated thoracic aorta. Compared with the prior study (images
reviewed) of [**2107-7-14**], there is now evidence of inferior
ischemia/infarction.

 Patient was discharged [**2109-7-8**]. He is to continue Aspirin,
Plavix, Pravastatin, Valsartan, and Lopressor and follow up with
his primary care doctor in one week and his cardiologist in one
month.
.
RHYTHM: Pt was sinus tachycardic on arrival to CCU. He had an
episode of 2:1 block during cath which resolved with atropine.
Pt was followed on telemetry and rate controlled with
metoprolol. He was stable through the course of his admission in
sinus rhythm.
.
# DM: Held metformin after dye load in cath. Last HgA1C in
[**5-/2109**] was 7.1. Pt was maintained on Insulin sliding scale
through the course of his admission. He was re-started on
metformin upon discharge.
.
HTN: Home medications of HCTZ and amlopidine were held during
admission, and not re-started upon discharge. Metoprolol was
increased to 75 mg daily and Valsartan was decreased in hospital
to 160 daily. He was discharged on these [**Year (4 digits) 4319**].
.
# Hyperlipidemia: Recent lipid panel in [**Month (only) **] showed: LDL 87, HDL
38, TG 64. Statin was increased to 80mg and he was discharged on
pravastatin 80 mg daily.
.
# s/p CVA: Patient with residual L-sided deficits with no
indication of new neurologic deficits. His Aspirin and statin
continued for stroke prevention.
.


Medications on Admission:
Amlodipine 10 mg daily - Holding
Plavix 75 mg daily - Continued
fluticasone nasal spray - Held
HCTZ 12.5 mg daily - Held
lorazepam 1 mg qHS - Continued
metformin SR 500 mg daily - Held
Toprol XL 50 mg daily - Changed
Pravastatin 20 mg qHS - Increased
Valsartan 320 mg daily - Changed
Terbinafine 1% cream once daily - Held
albuterol sulfate 90 mcg 2 puffs QID PRN - Continued


Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for sleep.
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Terbinafine 1 % Cream Sig: One (1) application Topical once a
day.
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB,
wheezing.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*1 bottle* Refills:*1*
9. Valsartan 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
ST Elevation Myocardial Infarction

Secondary:
Hyperlipidemia
Diabetes Type 2
Hypertension
History of Cerebrovascular Accident


Discharge Condition:
Good.  The patient's VS are stable, and he is able to ambulate
without difficulty.


Discharge Instructions:
You were admitted to the hospital because you had chest pain,
which was found to be a heart attack.  While you were here, you
underwent a cardiac catheterization, which demonstrated an
occlusion in one of your coronary arteries.  We opended the
artery with a balloon, and we started you on Aspirin, and you
will continue your Plavix, Toprol, Valsartan, and Pravastatin.

 DO NOT stop your Plavix. You must take it every day for one
year. DO NOT miss [**First Name (Titles) **] [**Last Name (Titles) 4319**]. Do not stop this medication unless
your cardiologist tells you to.

 Please do daily weights and call your doctor if your weight
more than 3 pounds in 1 day, or 6 pounds in 3 days. Please
follow a [**2099**] mg sodium diet.

While you were here, we started you on the following
medications:
1.  We STOPPED your Amlodipine
2.  We STOPPED your HCTZ
3.  We INCREASED your Pravastatin to 80 mg daily
4.  We INCREASED your Toprol XL to 75 mg daily
5.  We STARTED you on Aspirin 325 mg daily
6.  We STARTED you on Nitroglycerine as needed for your chest
pain.
7.  We DECREASED your Valsartan to 160 mg daily.


Please take all medications as prescribed.

Please keep all previously scheduled appointments. We will
schedule you to see Dr. [**Last Name (STitle) 8499**], your primary care doctor,
in one week and Dr [**Last Name (STitle) 696**] and Dr. [**First Name (STitle) 4135**], your cardiologists, in
2 weeks.

Please return to the ED or your healthcare provider if you
experience shortness of breath, chest pain, increasing
confusion, increased bleeding/swelling/tenderness in your groin,
fevers, chills, or any other concerning symptoms.

Followup Instructions:
You are scheduled to see Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 8499**] on [**2109-7-17**] at
3:15pm
Location: [**Location (un) 19035**]
Phone number: [**Telephone/Fax (1) 7976**]

You are scheduled to see Dr. [**Last Name (STitle) 696**] and Dr. [**First Name (STitle) 4135**], MD
Phone:[**Telephone/Fax (1) 62**] on [**2109-8-8**] at 8:00 AM


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Subendocardial infarction, initial episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of native coronary artery'}


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/STEMI

PRESENT ILLNESS: 66M with hx of DM, HTN, hyperlipidemia, s/p CVA with residual
left sided deficits, who presented to ED with chest pain and
found to have STEMI.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes +, Dyslipidemia +,
Hypertension +
2. CARDIAC HISTORY:  no documented hx of CAD; pt states heart
was "looked at" in past in DR, denies previous cardiac
catheterization.
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- s/p CVA - [**2106**] with L sided residual deficits which have
improved
- hypertension
- diabetes- metformin, daily FS at home 120s-190s
- hyperlipidemia
- asthma
- s/p R hydrocelectomy and R hernia repair

MEDICATION ON ADMISSION: Amlodipine 10 mg daily - Holding
Plavix 75 mg daily - Continued
fluticasone nasal spray - Held
HCTZ 12.5 mg daily - Held
lorazepam 1 mg qHS - Continued
metformin SR 500 mg daily - Held
Toprol XL 50 mg daily - Changed
Pravastatin 20 mg qHS - Increased
Valsartan 320 mg daily - Changed
Terbinafine 1% cream once daily - Held
albuterol sulfate 90 mcg 2 puffs QID PRN - Continued

ALLERGIES: Ace Inhibitors / Atenolol

PHYSICAL EXAM: PHYSICAL EXAMINATION:
GENERAL: WDWN overweight male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Small amt blood in mouth, gums oozing.
NECK: Supple, veins not distended; JVP difficult to appreciate,
<10cm
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.
Neuro: WNL except L-sided facial droop.
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: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Brother had large MI in mid-50s, Mother
and Sister w/ DM2. otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: Denies
-ETOH: occasional
-Illicit drugs: none 

### Response:
{'Subendocardial infarction, initial episode of care,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of native coronary artery'}
