CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 50 yo F s/p MI at age 38 p/w chest pressure, with radiation to
the left arm and throat, that began at 7 p.m. this evening. The
patient was seating, [**Location (un) 1131**] a dinner menu when the pain began.
She had associated lightheadedness and coldness but not nausea,
vomiting, or diaphoresis. The patient returned home, where she
took ASA 325 mg x 2 plus NTG SL x 1, with some relief. At around
8 p.m., she presented to the ED at [**Hospital3 **].

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

MEDICATION ON ADMISSION: Paroxetine
Flurbiprofen
ASA 81 mg daily (stopped used 2-3 weeks ago becaus she ran out)

ALLERGIES: Latex

PHYSICAL EXAM: (Per Admitting Resident)
VS: T=98.4 BP=110/71 HR=78 RR=15 O2 sat=97%/RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. No xanthalesma.
NECK: Supple. JVP not elevated.
CARDIAC: RRR. Normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normal bowel sounds. Soft, NTND. No HSM or tenderness.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Positive family history of stroke.

SOCIAL HISTORY: Married. Has two sons, aged 18 and 19.
-Tobacco history: Former smoker. Smoked from age 17 to age 38.
Initially smoked 1 pack/day, but was smoking 1.5 packs/week just
before she quit.
-ETOH: 4-5 drinks/week
-Illicit drugs: None. Specifically denies cocaine.
Subendocardial infarction, initial episode of care,Dissection of coronary artery,Anxiety state, unspecified
Subendo infarct, initial,Dissection cor artery,Anxiety state NOS
Admission Date:  [**2179-3-4**]              Discharge Date:   [**2179-3-6**]

Date of Birth:  [**2128-11-22**]             Sex:   F

Service: MEDICINE

Allergies:
Latex

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization

History of Present Illness:
50 yo F s/p MI at age 38 p/w chest pressure, with radiation to
the left arm and throat, that began at 7 p.m. this evening. The
patient was seating, [**Location (un) 1131**] a dinner menu when the pain began.
She had associated lightheadedness and coldness but not nausea,
vomiting, or diaphoresis. The patient returned home, where she
took ASA 325 mg x 2 plus NTG SL x 1, with some relief. At around
8 p.m., she presented to the ED at [**Hospital3 **].

At [**Hospital3 **], initial vital signs were T 97.5 P 59 RR 16
BP 92/73 Sat 98%. She was treated with NTG SL x 3 followed by
nitro drip, Plavix 300 mg PO, and heparin gtt.  The patient was
transferred to [**Hospital1 18**] for emergent cardiac catheterization.
Coronary angiography demonstrated long diffuse stenosis of the
RCA from the acute margin to the distal PL branch, with
appearance consistent with spontaneous dissection. During the
catheterization, the patient received fentanyl 12.5 mcg, heparin
gtt at 700 units/hr, nitroglycerin 200 mcg, and Versed 0.5 mg
IV.

On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, cough, 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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

Of note, the patient had similar symptoms 12 years ago, at which
time she reportedly had ischemic EKG changes but underwent
cardiac catheterization that showed clean coronaries.

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

2. CARDIAC HISTORY: as above
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-osteoarthritis
-s/p endometrial ablation [**2176**]

Social History:
Married. Has two sons, aged 18 and 19.
-Tobacco history: Former smoker. Smoked from age 17 to age 38.
Initially smoked 1 pack/day, but was smoking 1.5 packs/week just
before she quit.
-ETOH: 4-5 drinks/week
-Illicit drugs: None. Specifically denies cocaine.

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Positive family history of stroke.

Physical Exam:
(Per Admitting Resident)
VS: T=98.4 BP=110/71 HR=78 RR=15 O2 sat=97%/RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. No xanthalesma.
NECK: Supple. JVP not elevated.
CARDIAC: RRR. Normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normal bowel sounds. Soft, NTND. No HSM or tenderness.

EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: A+Ox3. CN II-XII intact.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+

Pertinent Results:
Admission Labs
[**2179-3-5**] 02:30AM BLOOD WBC-8.6 RBC-5.33 Hgb-11.8* Hct-36.8
MCV-69* MCH-22.1* MCHC-32.0 RDW-14.1 Plt Ct-255
[**2179-3-5**] 07:54AM BLOOD PT-12.9 PTT-39.0* INR(PT)-1.1
[**2179-3-5**] 02:30AM BLOOD Glucose-123* UreaN-10 Creat-0.6 Na-136
K-4.1 Cl-100 HCO3-28 AnGap-12
[**2179-3-5**] 02:30AM BLOOD Calcium-9.6 Phos-4.3 Mg-1.9 Cholest-185
[**2179-3-5**] 02:30AM BLOOD %HbA1c-5.2 eAG-103
[**2179-3-5**] 02:30AM BLOOD Triglyc-57 HDL-88 CHOL/HD-2.1 LDLcalc-86

Discharge Labs
[**2179-3-6**] 07:15AM BLOOD WBC-6.3 RBC-4.87 Hgb-11.1* Hct-34.0*
MCV-70* MCH-22.8* MCHC-32.6 RDW-14.4 Plt Ct-217
[**2179-3-6**] 07:15AM BLOOD PT-12.9 PTT-111.0* INR(PT)-1.1
[**2179-3-6**] 07:15AM BLOOD Glucose-97 UreaN-8 Creat-0.5 Na-138 K-3.9
Cl-103 HCO3-29 AnGap-10
[**2179-3-6**] 07:15AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0

Cardiac Biomarkers
[**2179-3-5**] 02:30AM BLOOD CK(CPK)-127
[**2179-3-5**] 02:30AM BLOOD CK-MB-15* MB Indx-11.8* cTropnT-0.05*

Cardiac Catheterization (PRELIMINARY REPORT):
1. Selective coronary angiography in this right dominant system
demonstrated single vessel disease. The LMCA had no
angiographically
apparent CAD.  The LAD had mild irregularities. The LCx had a
10%
proximal stenosis. The RCA had a long, diffuse stenosis from the
acute
marginal to the distal PL branch with a possible high take-off
of the
PDA; an appearance consistent with spontaneous dissection.
2. Left ventriculography revealed no significant mitral
regurgitation.
The ejection fraction was calculated to be 55% with inferoapical

hypokinesis.
FINAL DIAGNOSIS:
1. Probably spontaneous dissection of distal RCA.
2. Hypokinetic inferoapical segment.

Echocardiogram:
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 10-15mmHg. There is mild
regional left ventricular systolic dysfunction with focal apical
inferior hypokinesis. Overall left ventricular systolic function
is normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Mild regional (apical inferior) hypokinesis with
overall normal left ventricular systolic function.

Brief Hospital Course:
50 yo F with h/o vasospastic MI in the setting of clean
coronaries presents with NSTEMI from spontaneous RCA dissection.


# Spontaneous RCA Dissection - The patient presented with chest
pain and was found to have ACS.  Cardiac catheterization showed
spontaneous RCA dissection.  No intervention was performed at
that time.  The patient was started on full dose aspirin,
plavix, and heparin gtt.  Beta blocker was initially held due to
sinus bradycardia.  Echo was performed on the day following
admission and showed mild apical inferior hypokinesis with
overall normal left ventricular systolic function.  She was
continued on the heparin drip for 36 hours.  She remained free
of chest pain during her inpatient course.  At the time of
discharge, she was started on a beta blocker and high-dose
statin.  Prior to discharge, she was also started on a calcium
channel blocker.

# Anxiety - The patient was continued on her paroxetine.

Medications on Admission:
Paroxetine
Flurbiprofen
ASA 81 mg daily (stopped used 2-3 weeks ago becaus she ran out)

Vitamin C 500 mg daily

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily): Pills
may be cut in half.  However, pills should NOT be cruched or
chewed.
Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Flurbiprofen  Oral

Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis
Right Coronary Artery Dissection


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


Discharge Instructions:
You presented to the emergency department with chest discomfort.
 You were transferred to [**Hospital1 18**] for cardiac catheterization,
during which you were found to have a dissection in one of the
blood vessels supplying your heart.  You were placed on a
heparin drip to thin your blood for 36 hours.  You are also
being started some oral blood thinners which you will continue
to take at discharge.

CHANGES TO YOUR MEDICATIONS:
- INCREASE Aspirin to 325 mg daily
- START Plavix 75 mg daily - Discuss with your cardiologist how
long you should take this medication.
- START Atorvastatin 80 mg daily
- START Metoprolol Succinate 12.5 mg daily
- START Amlodipine 5 mg daily

It was a pleasure taking part in your medical care.

Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 1557**], MD Phone: ([**Telephone/Fax (1) 42482**] Date/time: [**3-24**] at
3:45pm.  Dr. [**First Name (STitle) 1557**] also wants to perform a stress test on you
within 1 week of discharge.  You should call his office on
Monday to schedule this.

Primary care:
[**First Name8 (NamePattern2) 6480**] [**Last Name (NamePattern1) 6402**], MD Phone: ([**Telephone/Fax (1) 42483**] Please keep any
scheduled appts.
{'Subendocardial infarction, initial episode of care,Dissection of coronary artery,Anxiety state, 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: 50 yo F s/p MI at age 38 p/w chest pressure, with radiation to
the left arm and throat, that began at 7 p.m. this evening. The
patient was seating, [**Location (un) 1131**] a dinner menu when the pain began.
She had associated lightheadedness and coldness but not nausea,
vomiting, or diaphoresis. The patient returned home, where she
took ASA 325 mg x 2 plus NTG SL x 1, with some relief. At around
8 p.m., she presented to the ED at [**Hospital3 **].

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

MEDICATION ON ADMISSION: Paroxetine
Flurbiprofen
ASA 81 mg daily (stopped used 2-3 weeks ago becaus she ran out)

ALLERGIES: Latex

PHYSICAL EXAM: (Per Admitting Resident)
VS: T=98.4 BP=110/71 HR=78 RR=15 O2 sat=97%/RA
GENERAL: WDWN woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. No xanthalesma.
NECK: Supple. JVP not elevated.
CARDIAC: RRR. Normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Normal bowel sounds. Soft, NTND. No HSM or tenderness.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Positive family history of stroke.

SOCIAL HISTORY: Married. Has two sons, aged 18 and 19.
-Tobacco history: Former smoker. Smoked from age 17 to age 38.
Initially smoked 1 pack/day, but was smoking 1.5 packs/week just
before she quit.
-ETOH: 4-5 drinks/week
-Illicit drugs: None. Specifically denies cocaine. 

### Response:
{'Subendocardial infarction, initial episode of care,Dissection of coronary artery,Anxiety state, unspecified'}
