CHIEF COMPLAINT: Sudden onset of chest pain

PRESENT ILLNESS: 87 y/o with history of HTN, atrial fibrillation, and
hyperlipidemia presents with sudden onset of CP at 2am . It
radiated to his neck and back. No dyspnea, diaphoresis at OSH.
He was found to have inferior ST elevations and complete heart
block w/BP 96/53, HR=43, RV4 w/ST elev. He was sent to [**Hospital1 **]
w/transcutaneous pacing, started on hep gtt, integrilin, ASA,
MSO4, guiac - by ED note. Received 2.5L IVF. In cath lab, he was
found to have RCA totally occluded in mid section w/prox
stenosis as well, and a tight OM1. RCA got 2 heparin coated
stents w/good result. Pressures: RA=16, PA=42/24, PCWP=24, PA
sat=49%. He also got atropine in cath lab on presentation.
Currently asymptomatic.

MEDICAL HISTORY: 1.HTN
2. AF
3. PVD (MRA BLE [**5-/2156**] showed 90% stenosis of superficial
femoral artery on right, 70-80% stenosis of prox popiteal artery
on left, severe stenosis of right ant tibial artery and
occlusion of bilat peroneal arteries)
4. COPD
5. Blind in R eye [**3-15**] chol emboli
6. Hypercholesterolemia
7. CN 6 paralysis
8. GIB [**6-/2156**] with EGD showing 2 small duodenal ulcers, prior
gastric ulcer
9. Depression
10. Cervical laminectomy

MEDICATION ON ADMISSION: 1.Coumadin 4 mg qd
2. Zoloft 150 qd
3. Norvasc 5 qd
4. Cozaar 25 qd
5. Lipitor 40 qd
6. Flomax 4 qd
7. Detrol 4 qd
8. Vioxx 25 qd
9. Combivent 2 puffs qid

ALLERGIES: Oxacillin

PHYSICAL EXAM: BP=101/42, HR=69, RR=20, 99% on 4LNC.
Gen: Elderly, alert, oriented, lying flat comfortably.
HEENT: EOMI, PERRLA, dilated equally, MM dry
Neck:No bruits, no LAD
CV:Distant heart sounds, RRR, nL S1,S2.  No MRG, No carotid
bruits.
Chest:Bibasilar rales anteriorly and laterally.
Abdomen:NT/ND, NABS, No organomegaly, Soft
Ext:No edema, cyanosis, clubbing, DP pulses are dopplerable.

FAMILY HISTORY: Not known to be contributory

SOCIAL HISTORY: Lives alone in independent living facility.
Smoked for 15 years, but stopped 40 years ago.
Acute myocardial infarction of other inferior wall, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Unspecified essential hypertension,Pure hypercholesterolemia
AMI inferior wall, init,Atrial fibrillation,Chr airway obstruct NEC,Crnry athrscl natve vssl,Renal & ureteral dis NOS,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2156-9-9**]              Discharge Date:   [**2156-9-13**]


Service: [**Hospital Unit Name 196**]

Allergies:
Oxacillin

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Sudden onset of chest pain

Major Surgical or Invasive Procedure:
Cardiac catheterization with 2 stents placed in RCA

History of Present Illness:
87 y/o with history of HTN, atrial fibrillation, and
hyperlipidemia presents with sudden onset of CP at 2am . It
radiated to his neck and back. No dyspnea, diaphoresis at OSH.
He was found to have inferior ST elevations and complete heart
block w/BP 96/53, HR=43, RV4 w/ST elev. He was sent to [**Hospital1 **]
w/transcutaneous pacing, started on hep gtt, integrilin, ASA,
MSO4, guiac - by ED note. Received 2.5L IVF. In cath lab, he was
found to have RCA totally occluded in mid section w/prox
stenosis as well, and a tight OM1. RCA got 2 heparin coated
stents w/good result. Pressures: RA=16, PA=42/24, PCWP=24, PA
sat=49%. He also got atropine in cath lab on presentation.
Currently asymptomatic.

Past Medical History:
1.HTN
2. AF
3. PVD (MRA BLE [**5-/2156**] showed 90% stenosis of superficial
femoral artery on right, 70-80% stenosis of prox popiteal artery
on left, severe stenosis of right ant tibial artery and
occlusion of bilat peroneal arteries)
4. COPD
5. Blind in R eye [**3-15**] chol emboli
6. Hypercholesterolemia
7. CN 6 paralysis
8. GIB [**6-/2156**] with EGD showing 2 small duodenal ulcers, prior
gastric ulcer
9. Depression
10. Cervical laminectomy


Social History:
Lives alone in independent living facility.
Smoked for 15 years, but stopped 40 years ago.


Family History:
Not known to be contributory

Physical Exam:
BP=101/42, HR=69, RR=20, 99% on 4LNC.
Gen: Elderly, alert, oriented, lying flat comfortably.
HEENT: EOMI, PERRLA, dilated equally, MM dry
Neck:No bruits, no LAD
CV:Distant heart sounds, RRR, nL S1,S2.  No MRG, No carotid
bruits.
Chest:Bibasilar rales anteriorly and laterally.
Abdomen:NT/ND, NABS, No organomegaly, Soft
Ext:No edema, cyanosis, clubbing, DP pulses are dopplerable.


Pertinent Results:
[**2156-9-9**] 10:45AM BLOOD WBC-7.3 RBC-3.80* Hgb-11.4*# Hct-35.2*
MCV-93 MCH-30.0 MCHC-32.4 RDW-14.0 Plt Ct-166
[**2156-9-9**] 05:06PM BLOOD Hct-33.7* Plt Ct-169
[**2156-9-10**] 01:00AM BLOOD Hct-33.8*
[**2156-9-11**] 06:30PM BLOOD WBC-7.7 RBC-3.85* Hgb-11.8* Hct-35.2*
MCV-91 MCH-30.6 MCHC-33.4 RDW-14.0 Plt Ct-148*
[**2156-9-12**] 05:40AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.7* Hct-32.9*
MCV-93 MCH-30.3 MCHC-32.6 RDW-13.9 Plt Ct-176
[**2156-9-9**] 10:45AM BLOOD Neuts-85.9* Lymphs-9.8* Monos-3.5 Eos-0.5
Baso-0.4
[**2156-9-12**] 05:40AM BLOOD Plt Ct-176

[**2156-9-9**] 10:45AM BLOOD PT-13.7* PTT-33.5 INR(PT)-1.2

[**2156-9-9**] 10:45AM BLOOD Glucose-119* UreaN-35* Creat-1.7* Na-141
K-4.8 Cl-111* HCO3-24 AnGap-11
[**2156-9-9**] 05:06PM BLOOD K-3.8
[**2156-9-10**] 01:00AM BLOOD Glucose-130* UreaN-29* Creat-1.6* Na-139
K-4.1 Cl-106 HCO3-24 AnGap-13
[**2156-9-11**] 06:30PM BLOOD Glucose-168* UreaN-32* Creat-1.7* Na-141
K-4.0 Cl-106 HCO3-24 AnGap-15
[**2156-9-12**] 05:40AM BLOOD Glucose-98 UreaN-34* Creat-1.8* Na-142
K-4.4 Cl-108 HCO3-24 AnGap-14

[**2156-9-11**] 06:30PM BLOOD ALT-50* AST-92* AlkPhos-114 TotBili-0.4

[**2156-9-9**] 10:45AM BLOOD CK(CPK)-697*
[**2156-9-9**] 05:06PM BLOOD CK(CPK)-1443*
[**2156-9-10**] 01:00AM BLOOD ALT-58* AST-223* CK(CPK)-1345*
AlkPhos-104 TotBili-0.5
[**2156-9-9**] 10:45AM BLOOD CK-MB-124* MB Indx-17.8* cTropnT-2.27*
[**2156-9-9**] 05:06PM BLOOD CK-MB-225* MB Indx-15.6*
[**2156-9-10**] 01:00AM BLOOD CK-MB-170* MB Indx-12.6*
[**2156-9-9**] 10:45AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 Cholest-131
[**2156-9-10**] 01:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9
[**2156-9-12**] 05:40AM BLOOD Mg-2.2

[**2156-9-9**] 10:45AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.8 LDLcalc-72
[**2156-9-11**] 06:30PM BLOOD TSH-2.8

Cardiac Cath:
COMMENTS:
1.  Selective coronary angiography revealed a right-dominant
system with
3-vessel coronary disease.  The LMCA was a short vessel with no
angiographically apparent disease.  The LAD was heavily
calcified and
diffusely diseased in the mid-vessel up to 70%.  The LCx was
diffusely
diseased in the mid-vessel with a long lesion up to 80%.  A
large OM1
branch had a 50-60% proximal stenosis.  The RCA was calcified
with a
total occlusion in the proximal vessel.
2.  Resting hemodynamics revealed moderately elevated right- and

left-sided filling pressures (mean RA 16 mmHg, mean PCW 22
mmHg).  There
was moderate pulmonary artery hypertension (mean PA 32 mmHg).
The
cardiac index was severely depressed at 1.6 L/min/m2.
3.  The patient entered the lab in complete heart block with an
escape
rate of 40 bpm.  A 5 French temporary pacing wire was placed in
the
right ventricle with successful capture and pacing at 60 bpm.
The
patient's heart block resolved and the pacing wire was was
removed at
the end of the case.
4.  Successful stenting of the mid RCA was performed with
overlapping
3.0 x 18 mm and 3.5 x 18 mm Hepacoat stents.
5.  Successful closure of the right groin was performed with a
6Fr
Angioseal device.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated filling pressures.
3. Acute inferior MI, terminated by primary PCI.
4. Angioseal of the groin.

Echo:
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Resting
regional wall
motion abnormalities include inferior akinesis and inferolateral
hypokinesis.
The right ventricular cavity is dilated. Right ventricular free
wall is not
fully visualized but systolic function appears depressed. The
aortic root is
moderately dilated. The aortic valve leaflets are mildly
thickened. There is
no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary
artery systolic hypertension. There is no pericardial effusion.


Compared with the findings of the prior study (tape reviewed) of
[**2152-12-29**],
regional wall motion abnormality is new and estimated pulmonary
artery
systolic pressure is now higher.

CXR:
IMPRESSION:

1. Patchy right lower lobe opacity, likely represent
atelectasis.

2. The previously described hazy opacity overlying the right
hemithorax is less apparent on the current study.

3. Small left pleural effusions.

4. Emphysema.


Brief Hospital Course:
Mr [**Known lastname **] was admitted from the cath lab after stenting of his
RCA to treat his ST elevation inferior MI and complete heart
block.  He recovered well from his MI and heart block and was
discharged to acute rehab due to deconditioning and recent
issues with falling/loss of balance.

Problems addressed included:
1. CAD: Initially was transcutaneously paced before cath.  Did
not require pacing afterwards.  His MI was inferior and appears
to involve the RV.  He was initially given ASA, Plavix, and 18
hours of integrilin.  His lipitor was increased to 80 mg qd.  He
was slowly started on an ACE-I as his BP would tolerate.  A
beta-blocker was then added and increased to his current dose of
metoprolol 25 mg [**Hospital1 **].  He tolerated these well.  No additional
chest pain during the admission.  His enzymes were cycled, and
his CK peaked at 1443.

2. Pump issues: He had an echo which showed an EF=45-50%, with
some akinetic areas.  His ACE-I was continued for afterload
reduction.  It was decided not to anticoagulate him due to
recent history of large GIB.  He had [**Last Name **] problem maintaining his
BP during admission.

3.EP/cardiac rhythm: He initially had a prolonged PR interval
and RBBB.  Also has h/o A fib.  Again, was decided that we would
not restart coumadin due to GIB risk.  He developed both
frequent NSVT and went into a fib while here.  He was started on
amiodarone (loading with 400 [**Hospital1 **] x7d, then 400 qd x7d, then 200
qd ongoing)and kept on his B-blocker.  This will address both
arrhythmias effectively in someone who is not likely a candidate
for an ICD if the NSVT continues. Baseline LFTs and TFTs were
obtained prior to amio.  He will need close follow-up of this
NSVT to determine effectiveness of amiodarone.  It was
asymptomatic while he was here.  He will have a Holter monitor
for 24 hours in several weeks after his amio load is complete,
and will then follow-up with EP to have this reevaluated and
further treatment prescribed.

4. CRI: He has CRI of unknown etiology.  His Cr was high, but
stable in 1.7 range.  It was followed closely as was his UOP,
which remained adequate.  His Flomax and Detrol were also
continued.

5. COPD: He had some wheezing during admission.  He was also on
O2 for much of the time, with reported SOB when he got up
without it.  He responded well to prn albuterol and atrovent
MDIs.  On discharge, he was maintaining adequate O2 sats off of
O2 and his wheezing was absent most of the time. He was sent out
on atrovent MDI for this.

6. ? lung infiltrate:  A "hazy opacity" was initially seen on
portable CXR.  Repeat PA/lateral reported that the "previously
described hazy opacity overlying R hemithorax was now less
apparent".  This will need to be followed with a repeat
Pa/lateral as an outpatient in 1 month to determine significance
and whether it needs to be further worked up.  No cough.

7.  He was discharged to rehab for acute conditioning.  He has
also been having increased number of falls and reports feeling
unsteady when walking.  This can be addressed at rehab.  Does
not sound like an acute event (stroke), but rather a chronically
progressive issue for him.

8.Follow-up: Needs to be seen for a follow-up CXR in about 1
month to evaluate his "hazy opacity" for changes.  Also needs to
follow-up with EP to evaluate his improvement after a full
amiodarone load.  We will try to schedule a Holter monitor for a
few days before this visit (after full load complete) so they
have information about his current rhythm.

Medications on Admission:
1.Coumadin 4 mg qd
2. Zoloft 150 qd
3. Norvasc 5 qd
4. Cozaar 25 qd
5. Lipitor 40 qd
6. Flomax 4 qd
7. Detrol 4 qd
8. Vioxx 25 qd
9. Combivent 2 puffs qid

Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Sertraline HCl 50 mg Tablet Sig: Three (3) Tablet PO QD (once
a day).
7. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
8. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic  PRN
(as needed).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Amiodarone HCl 200 mg Tablet Sig: as directed Tablet PO as
directed: Take 400 mg twice a day for 5 days, then take 400
mg/day for 7 days, then take 200 mg/day ongoing.
14. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
1.Inferior ST elevation Myocardial Infarction
2.Atrial fibrillation
3.COPD
4.Chronic Renal Insuffciency
5.GI BLEED


Discharge Condition:
Pt was stable without any chest pain.He did have some SOB with
activity and some unsteadiness when attempting to walk.Eating
well and no issues with cognition.

Discharge Instructions:
Please call your doctor or return to the hospital if you
experience new chest pain or shortness of breath.

Several new medications were started.  Please take notice of
these.
Most importantly, do not stop your Plavix medication for at
least 30 days as it is important for keeping your cardiac stents
from becoming blocked.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2156-9-14**] 4:00

Department of Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]- [**Telephone/Fax (1) 285**]-
[**2156-10-11**] at 11 AM.

[**Telephone/Fax (1) 3104**]- Holter Lab- [**2156-10-6**]- at 11AM

Please schedule an appointment to follow-up with your PCP [**Last Name (NamePattern4) **] 1
week of discharge from rehab. You will need a repeat chest X-ray
in [**4-15**] weeks as described in your discharge summary.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: Sudden onset of chest pain

PRESENT ILLNESS: 87 y/o with history of HTN, atrial fibrillation, and
hyperlipidemia presents with sudden onset of CP at 2am . It
radiated to his neck and back. No dyspnea, diaphoresis at OSH.
He was found to have inferior ST elevations and complete heart
block w/BP 96/53, HR=43, RV4 w/ST elev. He was sent to [**Hospital1 **]
w/transcutaneous pacing, started on hep gtt, integrilin, ASA,
MSO4, guiac - by ED note. Received 2.5L IVF. In cath lab, he was
found to have RCA totally occluded in mid section w/prox
stenosis as well, and a tight OM1. RCA got 2 heparin coated
stents w/good result. Pressures: RA=16, PA=42/24, PCWP=24, PA
sat=49%. He also got atropine in cath lab on presentation.
Currently asymptomatic.

MEDICAL HISTORY: 1.HTN
2. AF
3. PVD (MRA BLE [**5-/2156**] showed 90% stenosis of superficial
femoral artery on right, 70-80% stenosis of prox popiteal artery
on left, severe stenosis of right ant tibial artery and
occlusion of bilat peroneal arteries)
4. COPD
5. Blind in R eye [**3-15**] chol emboli
6. Hypercholesterolemia
7. CN 6 paralysis
8. GIB [**6-/2156**] with EGD showing 2 small duodenal ulcers, prior
gastric ulcer
9. Depression
10. Cervical laminectomy

MEDICATION ON ADMISSION: 1.Coumadin 4 mg qd
2. Zoloft 150 qd
3. Norvasc 5 qd
4. Cozaar 25 qd
5. Lipitor 40 qd
6. Flomax 4 qd
7. Detrol 4 qd
8. Vioxx 25 qd
9. Combivent 2 puffs qid

ALLERGIES: Oxacillin

PHYSICAL EXAM: BP=101/42, HR=69, RR=20, 99% on 4LNC.
Gen: Elderly, alert, oriented, lying flat comfortably.
HEENT: EOMI, PERRLA, dilated equally, MM dry
Neck:No bruits, no LAD
CV:Distant heart sounds, RRR, nL S1,S2.  No MRG, No carotid
bruits.
Chest:Bibasilar rales anteriorly and laterally.
Abdomen:NT/ND, NABS, No organomegaly, Soft
Ext:No edema, cyanosis, clubbing, DP pulses are dopplerable.

FAMILY HISTORY: Not known to be contributory

SOCIAL HISTORY: Lives alone in independent living facility.
Smoked for 15 years, but stopped 40 years ago. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Unspecified essential hypertension,Pure hypercholesterolemia'}
