CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 65 year old female past medical history significant for
Prader-Willi Syndrome, HTN, hyperlipidemia, developmental delay,
2 previous MI's, s/p cath in 96, 98, unknown results. Pt reports
onset of chest pain, substernal [**5-26**] non radiating, no
associated N/V/diaphoresis x 1 hour at rest in day program. Pt
to [**Location (un) 620**] [**Hospital1 69**], chest pain free
on arrival. EKG NSR@61, ST elevation V3, repeat NSR. CK-MB 34.9,
CPK 261, trop T 0.081. BP 140/76, HR 60. 1 liter NS given. Pt
given heparin bolus 3800 units, heparin GGT at 1000 units,
plavix loaded 600 mg, sent to [**Hospital1 18**]
.
Of note, pt previously admitted for chest pain NSTEMI to [**Location (un) 620**]
[**Date range (3) 68347**] for similar complaint NSTEMI, CK 266, MB 22.4,
trop 0.07. ECHO at that time with normal EF, nml wall motion, 1+
MR. She also reports fall this Sunday with abrasion, associated
with loss of balance, as per group home, PCP [**Name Initial (PRE) 12309**].

MEDICAL HISTORY: Prader-Willi syndrome
2 previous NTEMI's
Hypertension
ileostomy 96
schizo-affective disorder
SIADH - last admission

MEDICATION ON ADMISSION: Plavix 75 mg
Metoprolol 50 daily
Zestril 5 mg
lipitor 20 mg
ASA 325 mg
Protonix 40 qd
salt tablets [**Hospital1 **]
Depakote 750 [**Hospital1 **]
Ditropan XL 15 hs
Risperdal 4 [**Hospital1 **]
Pamelor 50 HS
Synthroid 75 mcg
Tylenol
Glucosamine
Multivitamins

ALLERGIES: Amoxicillin / Ciprofloxacin / Percocet / Augmentin

PHYSICAL EXAM: ADMISSION EXAM
Vitals- 97.8, 158/75, 64, 18, 98%, 0/10 pain
General- short, smiling female in no acute distress, with
bandage on head.
HEENT- abrasion forehead left, blood on gauze. No other
abrasions or lacerations. PERRL. No JVP appreciated.
CV- RRR, no M/R/G
lungs- CTAB, no wheezes noted.
Abdomen- surgical scar vertical, non tender, slight distenstion.
+ BS
groin- 2 + fem pulses
Extr- no edema, cyanosis, clubbing, foot deformity bilaterally,
2+DP
Small hands.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives in a group home. Parents deceased x 20 + years. Healthcare
proxy is [**Name (NI) 1439**] [**Name (NI) 1968**], [**Telephone/Fax (1) 68348**]. Unable to assess hx
further.
Other chest pain,Acute posthemorrhagic anemia,Angiodysplasia of stomach and duodenum with hemorrhage,Pneumonitis due to inhalation of food or vomitus,Schizoaffective disorder, unspecified,Other specified disorders of esophagus,Other and unspecified hyperlipidemia,Prader-Willi syndrome,Unspecified essential hypertension,Other disorders of neurohypophysis,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Old myocardial infarction
Chest pain NEC,Ac posthemorrhag anemia,Angio stm/dudn w hmrhg,Food/vomit pneumonitis,Schizoaffective dis NOS,Other dsrders esophagus,Hyperlipidemia NEC/NOS,Prader-willi syndrome,Hypertension NOS,Neurohypophysis dis NEC,Adv eff antipsychotc NEC,Hypothyroidism NOS,Old myocardial infarct
Admission Date:  [**2194-8-5**]              Discharge Date:   [**2194-8-19**]

Date of Birth:  [**2125-9-26**]             Sex:   F

Service: MEDICINE

Allergies:
Amoxicillin / Ciprofloxacin / Percocet / Augmentin

Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
chest pain


Major Surgical or Invasive Procedure:
Cardiac catheterization
EGD


History of Present Illness:
65 year old female past medical history significant for
Prader-Willi Syndrome, HTN, hyperlipidemia, developmental delay,
2 previous MI's, s/p cath in 96, 98, unknown results. Pt reports
onset of chest pain, substernal [**5-26**] non radiating, no
associated N/V/diaphoresis x 1 hour at rest in day program. Pt
to [**Location (un) 620**] [**Hospital1 69**], chest pain free
on arrival. EKG NSR@61, ST elevation V3, repeat NSR. CK-MB 34.9,
CPK 261, trop T 0.081. BP 140/76, HR 60. 1 liter NS given. Pt
given heparin bolus 3800 units, heparin GGT at 1000 units,
plavix loaded 600 mg, sent to [**Hospital1 18**]
.
Of note, pt previously admitted for chest pain NSTEMI to [**Location (un) 620**]
[**Date range (3) 68347**] for similar complaint NSTEMI, CK 266, MB 22.4,
trop 0.07. ECHO at that time with normal EF, nml wall motion, 1+
MR. She also reports fall this Sunday with abrasion, associated
with loss of balance, as per group home, PCP [**Name Initial (PRE) 12309**].

Past Medical History:
Prader-Willi syndrome
2 previous NTEMI's
Hypertension
ileostomy 96
schizo-affective disorder
SIADH - last admission


Social History:
Lives in a group home. Parents deceased x 20 + years. Healthcare
proxy is [**Name (NI) 1439**] [**Name (NI) 1968**], [**Telephone/Fax (1) 68348**]. Unable to assess hx
further.



Family History:
Unknown

Physical Exam:
ADMISSION EXAM
Vitals- 97.8, 158/75, 64, 18, 98%, 0/10 pain
General- short, smiling female in no acute distress, with
bandage on head.
HEENT- abrasion forehead left, blood on gauze. No other
abrasions or lacerations. PERRL. No JVP appreciated.
CV- RRR, no M/R/G
lungs- CTAB, no wheezes noted.
Abdomen- surgical scar vertical, non tender, slight distenstion.
+ BS
groin- 2 + fem pulses
Extr- no edema, cyanosis, clubbing, foot deformity bilaterally,
2+DP
Small hands.

Pertinent Results:
[**2194-8-5**] 09:50PM   CK-MB-20* MB INDX-9.7* cTropnT-0.09*
[**2194-8-5**] 09:50PM   CK(CPK)-207*
[**2194-8-5**] 10:22PM   PTT-150*

[**2194-8-6**] - C.CATH
1. Selective coronary angiography revealed a right dominant
system with
LMCA, LAD and LMCX that were free of angiographically apparent
disease
and an RCA that had a 20% proximal lesion but was otherwise free
of
disease.
2. Left ventriculography showed normal function.
3. Limited hemodynamic assessment showed low normal systemic
aortic
pressures.
Findings
1. Coronary arteries are normal.
2. Normal ventricular function.
.
[**2194-8-7**] - ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is unusually small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 70%). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion 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. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
.
[**2194-8-8**] - CHEST (PA & LAT)
1. Right retrocardiac opacity which likely represents pneumonia.
2. Leftward deviation of the trachea. This may be due to a
multinodular goiter. CT chest examination can be performed if
clinically indicated.
.
[**2194-8-8**] - EGD
Small hiatal hernia
Esophageal erosion
Angioectasias in the fundus, stomach body and antrum
Angioectasias in the duodenal bulb, first part of the duodenum
and second part of the duodenum
Otherwise normal EGD to second part of the duodenum

Brief Hospital Course:
1) Chest pain
Ms. [**Known lastname 68349**] chest pain was initally considered to be unstable
angina in the setting of moderately elevated enzymes and two
previous MI's in the past. Other things in the differential
diagnosis included GERD, costochondral pain, coronary vasospasm,
myocarditis and pleuritic pain. There were no acute EKG changes.
Troponin was borderline at 0.08 and MB mildly positive. The
patient underwent cardiac catheterization which demonstrated 20%
proximal RCA stenosis, but was otherwise clean and no
intervention was deemed necessary. Her symptoms may have been
related to coronary vasospasm, however her upper GI pathology
noted on EGD (see below), was also likely contributed. Given
non-flow limiting coronary artery disease and upper GI bleed,
she was maintained off ASA and Plavis.

2) Upper GI bleed:
Ms. [**Known lastname **] developed hematemesis/coffee-ground emesis
following Plavix load and heparin drip. Heparin, plavix and
aspirin were held and she was started on IV PPI. EGD showed
diffuse angioectasias throughout stomach and down to duodenal
bulb, along with esophageal erosions. She was transferred to
MICU for further managment and developed melana. She was
transfused a total of 4U PRBCs, 2FFP and 1 bag platelets. Hct
stabilized and she was transferred to the floor. Her GI bleeding
was most likely precipitated by heparin/plavix. Given diffuse
nature of AVMs, no endoscopic intervention was possible. The
surgical service was consulted, however they did not recommend
surgery (which would need to be extensive), given stabilization
of the patient's hematocrit.  She has scheduled follow-up with
Gasteroenterology at [**Hospital1 18**] and they will decide whether or not
to perform a follow-up EGD. She should have a colonoscopy as an
outpatient.

3) Aspiration Pneumonia/Pneumonitis
The patient developed crackles after the episode of hematemesis.
This finding raised concern for pneumonia versus an aspiration
pneumonitis. CXR demonstrated retrocardiac opacity, but the
patient remained afebrile, without a leukocytosis or symptoms.
Thus, antibiotic coverage was not initiated. Lungs were clear at
discharge and the patient was stable on room air. She underwent
a bedside speech and swallow evaluation, along with a video
swallow study. This revealed mild oropharyngeal dysphagia with
aspiration of clear liquids. She should adhere to a soft
solids/thickened liquid diet to avoid future aspiration. She
will need outpatient follow-up for tracheal deviation
demonstrated on CXR. There was some concern for thyroid
pathophysiology. TSH was slightly elevated. Levothyroxine was
increased to 100 micrograms per day.  She will need repeat
thyroid studies 6 weeks following discharge.

4) SIADH
She was continued on salt tablets for known hyponatremia likely
secondary to anti-psychotic induced SIADH. She was continued on
her home doses of anti-psychotics for her schizo-affective
disorder.

Given the patient's need for physical therapy and ambulation
with a walker, she was discharged to a rehabilitation facility.

Medications on Admission:
Plavix 75 mg
Metoprolol 50 daily
Zestril 5 mg
lipitor 20 mg
ASA 325 mg
Protonix 40 qd
salt tablets [**Hospital1 **]
Depakote 750 [**Hospital1 **]
Ditropan XL 15 hs
Risperdal 4 [**Hospital1 **]
Pamelor 50 HS
Synthroid 75 mcg
Tylenol
Glucosamine
Multivitamins


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day): please
take 750 mg twice a day just as you previously had. .
7. Nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
9. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).

11. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Nasal once a day.
13. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*5*
14. Risperidone 1 mg Tablet Sig: Four (4) Tablet PO BID (2 times
a day).
15. Sucralfate 100 mg/mL Suspension Sig: Ten (10) mL PO qid.
Disp:*1 month* Refills:*5*
16. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
Lifecare of [**Location (un) **]

Discharge Diagnosis:
Primary:
chest pain - cath with clean coronaries- no intervention
performed.

Secondary:
Upper GI bleed
SIADH
Hypertension, Schizoaffective disorder
Hypothyroidism

Discharge Condition:
stable


Discharge Instructions:
You were admitted with chest pain and had elevated enzymes. You
had a cardiac catheterization which showed clean coronaries, and
no intervention was thus needed. You had an upper GI bleed which
has resolved.
-Please do not take aspirin or plavix given GI bleed.
- Addition of Norvasc 5 mg.
-Please take your salt tablets as you previously had, and go to
get your sodium level checked tomorrow with Dr. [**Last Name (STitle) 17567**].
-Please keep all appointments
-Please return to the hospital if you are experiencing chest
pain, shortness of breath, fainting or any other symptoms
concerning to you.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 17567**] in 2 weeks. You can make an
appointment by calling [**Telephone/Fax (1) 17568**]. He should check your
hematocrit.
- given your levothyroxine dose was increased, you should have
repeat thyroid function tests checked in 6 weeks.
- you should have an outpatient colonoscopy
.
Please follow-up with Dr. [**Last Name (STitle) **] (Cardiology) on [**8-20**] at
2:30pm. [**Telephone/Fax (1) 4105**].
.
Please follow-up with Dr. [**Last Name (STitle) **] (Gasteroenterology) on Monday,
[**9-8**] at 3pm. [**Hospital Ward Name 23**] Bldg. [**Location (un) 436**]. Phone:
[**Telephone/Fax (1) 1954**]


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
{'Other chest pain,Acute posthemorrhagic anemia,Angiodysplasia of stomach and duodenum with hemorrhage,Pneumonitis due to inhalation of food or vomitus,Schizoaffective disorder, unspecified,Other specified disorders of esophagus,Other and unspecified hyperlipidemia,Prader-Willi syndrome,Unspecified essential hypertension,Other disorders of neurohypophysis,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Old myocardial infarction'}


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: 65 year old female past medical history significant for
Prader-Willi Syndrome, HTN, hyperlipidemia, developmental delay,
2 previous MI's, s/p cath in 96, 98, unknown results. Pt reports
onset of chest pain, substernal [**5-26**] non radiating, no
associated N/V/diaphoresis x 1 hour at rest in day program. Pt
to [**Location (un) 620**] [**Hospital1 69**], chest pain free
on arrival. EKG NSR@61, ST elevation V3, repeat NSR. CK-MB 34.9,
CPK 261, trop T 0.081. BP 140/76, HR 60. 1 liter NS given. Pt
given heparin bolus 3800 units, heparin GGT at 1000 units,
plavix loaded 600 mg, sent to [**Hospital1 18**]
.
Of note, pt previously admitted for chest pain NSTEMI to [**Location (un) 620**]
[**Date range (3) 68347**] for similar complaint NSTEMI, CK 266, MB 22.4,
trop 0.07. ECHO at that time with normal EF, nml wall motion, 1+
MR. She also reports fall this Sunday with abrasion, associated
with loss of balance, as per group home, PCP [**Name Initial (PRE) 12309**].

MEDICAL HISTORY: Prader-Willi syndrome
2 previous NTEMI's
Hypertension
ileostomy 96
schizo-affective disorder
SIADH - last admission

MEDICATION ON ADMISSION: Plavix 75 mg
Metoprolol 50 daily
Zestril 5 mg
lipitor 20 mg
ASA 325 mg
Protonix 40 qd
salt tablets [**Hospital1 **]
Depakote 750 [**Hospital1 **]
Ditropan XL 15 hs
Risperdal 4 [**Hospital1 **]
Pamelor 50 HS
Synthroid 75 mcg
Tylenol
Glucosamine
Multivitamins

ALLERGIES: Amoxicillin / Ciprofloxacin / Percocet / Augmentin

PHYSICAL EXAM: ADMISSION EXAM
Vitals- 97.8, 158/75, 64, 18, 98%, 0/10 pain
General- short, smiling female in no acute distress, with
bandage on head.
HEENT- abrasion forehead left, blood on gauze. No other
abrasions or lacerations. PERRL. No JVP appreciated.
CV- RRR, no M/R/G
lungs- CTAB, no wheezes noted.
Abdomen- surgical scar vertical, non tender, slight distenstion.
+ BS
groin- 2 + fem pulses
Extr- no edema, cyanosis, clubbing, foot deformity bilaterally,
2+DP
Small hands.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives in a group home. Parents deceased x 20 + years. Healthcare
proxy is [**Name (NI) 1439**] [**Name (NI) 1968**], [**Telephone/Fax (1) 68348**]. Unable to assess hx
further. 

### Response:
{'Other chest pain,Acute posthemorrhagic anemia,Angiodysplasia of stomach and duodenum with hemorrhage,Pneumonitis due to inhalation of food or vomitus,Schizoaffective disorder, unspecified,Other specified disorders of esophagus,Other and unspecified hyperlipidemia,Prader-Willi syndrome,Unspecified essential hypertension,Other disorders of neurohypophysis,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use,Unspecified acquired hypothyroidism,Old myocardial infarction'}
