CHIEF COMPLAINT: left shoulder pain

PRESENT ILLNESS: Patient reports that she first experienced pain in her left
shoulder and radiating down her left arm yesterday morning.  She
was not exerting herself, not eating, she was playing cards
which she usually does most mornings before breakfast.  The pain
was very difficult to describe, not sharp or dull per se, she
thought it was her arthritis.  Lasted about 10 minutes and
spontaneously resolved without interventions.  Then this morning
she had another episode of similar left shoulder pain this am,
lasting a little longer, maybe about 1-2 hours.  She denies
having shortness of breath, nausea, or diaphoresis with these
episodes.  With the pain this am she had a second of
lightheadedness and that is why she decided to come in to the
hospital for it.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:  occluded RCA and s/p DES to LAD
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  DES to LAD [**2111**]
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
peripheral vascular disease s/p right fem-[**Doctor Last Name **] bypass [**2111**]
s/p L CEA [**2111**]
arthritis
bladder incontinence--? overflow incontinence

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Lipitor 20 mg PO DAILY
2. Valsartan 160 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY

ALLERGIES: Percocet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T98.6, BP 137/74, HR 77, RR 18, O2 sat=97% RA
GENERAL: WDWN F 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.

FAMILY HISTORY: NC, 84 yo

SOCIAL HISTORY: Retired economist.  Originally from [**Location (un) 6079**], [**Country 532**].  Has
lived in [**Location 86**] for 19 years with her husband.  She is the
caretaker and they both attend daycare during the week.
-Tobacco history:  none
-ETOH:  one drink per 6 months
-Illicit drugs:  denies
Acute myocardial infarction of unspecified site, initial episode of care,Acute systolic heart failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Arthropathy, unspecified, site unspecified,Overflow incontinence,Percutaneous transluminal coronary angioplasty status
AMI NOS, initial,Ac systolic hrt failure,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Hypertension NOS,Periph vascular dis NOS,Arthropathy NOS-unspec,Overflow incontinence,Status-post ptca
Admission Date:  [**2122-5-25**]              Discharge Date:   [**2122-5-28**]

Date of Birth:  [**2037-11-9**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
left shoulder pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2122-5-25**] with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**]


History of Present Illness:
Patient reports that she first experienced pain in her left
shoulder and radiating down her left arm yesterday morning.  She
was not exerting herself, not eating, she was playing cards
which she usually does most mornings before breakfast.  The pain
was very difficult to describe, not sharp or dull per se, she
thought it was her arthritis.  Lasted about 10 minutes and
spontaneously resolved without interventions.  Then this morning
she had another episode of similar left shoulder pain this am,
lasting a little longer, maybe about 1-2 hours.  She denies
having shortness of breath, nausea, or diaphoresis with these
episodes.  With the pain this am she had a second of
lightheadedness and that is why she decided to come in to the
hospital for it.

In the ED, initial vitals were 97.2 88 122/62 16 99% 2L NC.
Labs and imaging significant for troponin of 0.25 with normal
renal function and EKG with ST elevations in aVR and lead III >
II as well as depressions in I, II, V4-V6.  Otherwise NA/NI,
rate 80s, + LVH and LAE. Patient given heparin gtt, morphine,
and NTG in the ED then  taken immediately by cardiology to the
cath lab.  In the lab, she had totally occluded RCA, which was
old from [**2111**] and previous stent to LAD was patent.   Occluded
OM off a tortuous circ.  DES to circ to obstuse marginal.
Angioplasty to native circumflex. Perclose.
.
On arrival to the floor, patient is feeling well, no more pain
in the left shoulder.  She does not have any complaints.  She
does report history of caludication symptoms in the past and
some chronic shortness of breath, not exertional.  Denies PND.
.
REVIEW OF SYSTEMS
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 reports exertional 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.


Past Medical History:
. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:  occluded RCA and s/p DES to LAD
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  DES to LAD [**2111**]
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
peripheral vascular disease s/p right fem-[**Doctor Last Name **] bypass [**2111**]
s/p L CEA [**2111**]
arthritis
bladder incontinence--? overflow incontinence

Social History:
Retired economist.  Originally from [**Location (un) 6079**], [**Country 532**].  Has
lived in [**Location 86**] for 19 years with her husband.  She is the
caretaker and they both attend daycare during the week.
-Tobacco history:  none
-ETOH:  one drink per 6 months
-Illicit drugs:  denies

Family History:
NC, 84 yo

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.6, BP 137/74, HR 77, RR 18, O2 sat=97% RA
GENERAL: WDWN F 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.

NECK: Supple with JVP of 5 cm.
CARDIAC: 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 in left groin, dressing
c/d/i.
SKIN: + stasis dermatitis, no ulcers, scars, or xanthomas.
NEURO; 5/5 strength b/l in dermatomes C5-T1 and L4-S1 and
sensation intact to the same dermatomes.  CN 2-12 intact
PULSES:
Right: radial 2+ DP 2+ PT 1+
Left: radial 2+ DP 2+ PT 1+

DISCHARGE PHYSICAL EXAM
VS afebrile, BP 100-120s/80s, HR 70-80s, saturations > 97% RA
exam unchanged

Pertinent Results:
ADMISSION LABS:
[**2122-5-25**] 11:55AM BLOOD WBC-8.4 RBC-4.16* Hgb-12.3 Hct-37.5
MCV-90 MCH-29.7 MCHC-32.9 RDW-14.3 Plt Ct-291
[**2122-5-25**] 11:55AM BLOOD Neuts-81.5* Lymphs-14.3* Monos-2.2
Eos-1.4 Baso-0.5
[**2122-5-25**] 11:55AM BLOOD PT-11.0 PTT-31.5 INR(PT)-1.0
[**2122-5-25**] 11:55AM BLOOD Glucose-140* UreaN-26* Creat-0.9 Na-140
K-4.0 Cl-103 HCO3-31 AnGap-10
[**2122-5-25**] 11:55AM BLOOD CK(CPK)-188
[**2122-5-25**] 11:55AM BLOOD CK-MB-17* MB Indx-9.0*
[**2122-5-25**] 11:55AM BLOOD cTropnT-0.25*
[**2122-5-25**] 11:55AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0
.
IMAGING:
[**2122-5-25**] CARDIAC CATH: 1) Selective angiography of this
right-dominant system demonstrated
significant three-vessel coronary artery disease.  The LMCA was
free of
angiographically-apparent flow-limiting stenoses.  The LAD had a
patent
proximal stent, with a long 60-70% mid-vessel eccentric
calcified
stenosis.  The LCx system had a 100% stenosis of a major OM
branch;
there was also a 90% mid-vessel stenosis.  The RCA was known to
have a
100% mid-vessel stenosis and filled via left-to-right
collaterals.
2) Limited resting hemodynamics revealed systemic arterial
normotension, with a central aortic pressure of 132/67 mmHg.
3) Successful PTCA of the LCx with a 2.5 mm balloon (see PTCA
comments).
4) Successful PTCA and stenting of the LCx into a major obtuse
marginal
branch with a 3.0 x 30 mm Resolute [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.25 mm
(see PTCA
comments).
5) Successful RFA Perclose (see PTCA comments).

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA of the LCx with a 2.5 mm balloon.
3. Successful PCI of the LCx into a large obtuse marginal branch
with a
3.0 x 30 mm Resolute [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 7930**] to 3.25 mm.
4. Successful RFA Perclose.

[**5-26**] tte: LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Moderately depressed LVEF. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. RV function depressed.

AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Focal calcifications in ascending aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS. Mild
(1+) MR. [Due to acoustic shadowing, the severity of MR may be
significantly UNDERestimated.]

TRICUSPID VALVE: Normal tricuspid valve leaflets. Normal
tricuspid valve supporting structures. No TS. Mild [1+] TR.
Borderline PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PS. Normal main PA. No Doppler evidence for PDA

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.

Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is moderately
depressed (LVEF= 35 %) secondary to severe hypokinesis of the
inferior, posterior, and lateral walls. The right ventricular
free wall thickness is normal. Right ventricular chamber size is
normal. with depressed free wall contractility. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.

Brief Hospital Course:
Ms. [**Known lastname 11154**] is a 84 year old female with known coronary artery
disease (CAD) who presented with left shoulder pain, found to
have ST elevations in aVR and ST depressions diffusely, with
troponin elevations.  She was admitted to the CCU after
placement of drug eluding stent (DES) to left circumflex (LCx).
.
# CAD:  Has 3 vessel disease (3VD) on cath this admission, with
DES placed to Lcx on [**2122-5-25**].  Also known 100% occlusion of RCA,
LAD with 60-70% mid-vessel disease but patent proximal DES (from
[**2111**]).  Post-cath her EKG showed resolution of her ST changes
and her CKMB peaked at 153.  Her echo showed new EF 35% with
inferior hypokinesis.  She was continued on valsartan 80 mg
daily and her atenolol was changed to metoprolol succinate 100
mg daily.  She was also dicharged on aspirin 81 mg daily and
clopidogrel 75 mg daily.  Physical therapy saw her and
recommended home with home PT.
.
# New systolic heart failure:  Had decreased EF to 35% after her
MI and crackles on exam.  Responded well to furosemide 20 mg
daily, continued metoprolol succinate 100 mg daily.  She should
be set up with heart failure clinic.  Should have another echo
checked at follow-up and if remains in low EF then consider for
ICD placement.
.
#  Arthritis:  Was given tylenol for pain, continued vytorin gel
at home.
.
#  Bladder incontinence: chronic, sounding like overflow
incontinence.  [**Month (only) 116**] also have a contribution from chronic
constipation.  Was given senna, docusate, and miralax as an
inpatient and her stools improved.
.
CODE: confirmed full
EMERGENCY CONTACT: daughter [**Name (NI) 335**], [**Telephone/Fax (1) 11155**]
.
TRANSITIONAL ISSUES:
- Should have another echo checked at follow-up and if remains
in low EF then consider for ICD placement and also
spironolactone.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Lipitor 20 mg PO DAILY
2. Valsartan 160 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY


Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one Tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Valsartan 80 mg PO DAILY
Please hold for SBP < 100
RX *Diovan 80 mg one Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
5. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg one Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg one Tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. Furosemide 20 mg PO DAILY
Please hold for SBP < 100
RX *furosemide 20 mg one Tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
8. Metoprolol Succinate XL 50 mg PO DAILY
Hold for SBP<100 or HR<60
RX *metoprolol succinate 50 mg ONE Tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2


Discharge Disposition:
Home

Discharge Diagnosis:
ST elevation acute myocardial infarction
Dyslipidemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 11154**],
You were admitted to the hospital because you had a heart
attack. You were taken to the cath lab where they saw a blockage
in one of the vessels supplying the heart muscle with blood and
had a drug eluting stent to open up this blood vessel.  You
tolerated this procedure well and were monitored in the CCU for
an evening. Your heart is weak after the heart attack, it will
probably get stronger over the next month but you have been
started on new medicines to help the heart recover.

Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2122-6-1**] at 12:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: THURSDAY [**2122-6-4**] at 11:00 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: VASCULAR SURGERY
When: WEDNESDAY [**2122-7-8**] at 10:45 AM
With:  VASCULAR LMOB (NHB) [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appointment: Thursday [**2122-6-4**] 1:45pm
{'Acute myocardial infarction of unspecified site, initial episode of care,Acute systolic heart failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Arthropathy, unspecified, site unspecified,Overflow incontinence,Percutaneous transluminal coronary angioplasty status'}


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: left shoulder pain

PRESENT ILLNESS: Patient reports that she first experienced pain in her left
shoulder and radiating down her left arm yesterday morning.  She
was not exerting herself, not eating, she was playing cards
which she usually does most mornings before breakfast.  The pain
was very difficult to describe, not sharp or dull per se, she
thought it was her arthritis.  Lasted about 10 minutes and
spontaneously resolved without interventions.  Then this morning
she had another episode of similar left shoulder pain this am,
lasting a little longer, maybe about 1-2 hours.  She denies
having shortness of breath, nausea, or diaphoresis with these
episodes.  With the pain this am she had a second of
lightheadedness and that is why she decided to come in to the
hospital for it.

MEDICAL HISTORY: . CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:  occluded RCA and s/p DES to LAD
-CABG:  none
-PERCUTANEOUS CORONARY INTERVENTIONS:  DES to LAD [**2111**]
-PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
peripheral vascular disease s/p right fem-[**Doctor Last Name **] bypass [**2111**]
s/p L CEA [**2111**]
arthritis
bladder incontinence--? overflow incontinence

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Pharmacy.
1. Lipitor 20 mg PO DAILY
2. Valsartan 160 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY

ALLERGIES: Percocet

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: T98.6, BP 137/74, HR 77, RR 18, O2 sat=97% RA
GENERAL: WDWN F 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.

FAMILY HISTORY: NC, 84 yo

SOCIAL HISTORY: Retired economist.  Originally from [**Location (un) 6079**], [**Country 532**].  Has
lived in [**Location 86**] for 19 years with her husband.  She is the
caretaker and they both attend daycare during the week.
-Tobacco history:  none
-ETOH:  one drink per 6 months
-Illicit drugs:  denies 

### Response:
{'Acute myocardial infarction of unspecified site, initial episode of care,Acute systolic heart failure,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Arthropathy, unspecified, site unspecified,Overflow incontinence,Percutaneous transluminal coronary angioplasty status'}
