CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: Mr. [**Known lastname 101177**] is a 59M letter carrier who was working the night
shift when he had chest pressure, b/l jaw pain, diaphoresis, and
nausea. He went to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101178**] where he had an EKG that
showed II>III STE. No RV or posterior leads were started. A
nitro gtt was briefly started but discontinued abruptly prior to
transfer at the reccomendations of our cardiology fellow. He was
given ASA, Plavix load, G32B inhibitor and heparin. He had some
bradycardia to the 30's. He was transferred to [**Hospital1 18**] cath lab
for urgent intervention.
.
He was found to have 100% occlusion of large OM1. A BMS was
deployed with some mild STE without chest pain felt to be
reperfusuion. He is currently CP free. He did get bivalirudin
during the case.  On the CCU, he says he feels "great" and
denies CP, HA, SOB, abdom pain, chest pressure. At baseline, he
does cardio exercise 3-4x/wk doing stairmaster or spinning

MEDICAL HISTORY: ??Inflammatory arthritis (lupus per pt)
[**Name (NI) 101179**]

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Prednisone 10mg daily for past month
Levothyroxine, unknown dose
.

ALLERGIES: Tapazole

PHYSICAL EXAM: ADMISSION EXAM:
GENERAL: 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: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  still alive, no cardiac Hx
- Father:  still alive at 83, had CABG in 60s

SOCIAL HISTORY: The patient works in the post office.  No tobacco use since
early [**2158**].  No alcohol use.
Acute myocardial infarction of unspecified site, initial episode of care,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other specified inflammatory polyarthropathies,Unspecified acquired hypothyroidism,Other specified cardiac dysrhythmias
AMI NOS, initial,Acute kidney failure NOS,Crnry athrscl natve vssl,Inflamm polyarthrop NEC,Hypothyroidism NOS,Cardiac dysrhythmias NEC
Admission Date:  [**2191-3-27**]              Discharge Date:   [**2191-3-30**]

Date of Birth:  [**2131-6-20**]             Sex:   M

Service: MEDICINE

Allergies:
Tapazole

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
cath lab for urgent intervention: stenting of OM1 with bare
metal stent


History of Present Illness:
Mr. [**Known lastname 101177**] is a 59M letter carrier who was working the night
shift when he had chest pressure, b/l jaw pain, diaphoresis, and
nausea. He went to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101178**] where he had an EKG that
showed II>III STE. No RV or posterior leads were started. A
nitro gtt was briefly started but discontinued abruptly prior to
transfer at the reccomendations of our cardiology fellow. He was
given ASA, Plavix load, G32B inhibitor and heparin. He had some
bradycardia to the 30's. He was transferred to [**Hospital1 18**] cath lab
for urgent intervention.
.
He was found to have 100% occlusion of large OM1. A BMS was
deployed with some mild STE without chest pain felt to be
reperfusuion. He is currently CP free. He did get bivalirudin
during the case.  On the CCU, he says he feels "great" and
denies CP, HA, SOB, abdom pain, chest pressure. At baseline, he
does cardio exercise 3-4x/wk doing stairmaster or spinning

Past Medical History:
??Inflammatory arthritis (lupus per pt)
[**Name (NI) 101179**]

Social History:
The patient works in the post office.  No tobacco use since
early [**2158**].  No alcohol use.


Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  still alive, no cardiac Hx
- Father:  still alive at 83, had CABG in 60s

Physical Exam:
ADMISSION EXAM:
GENERAL: 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 6-7cm.  No carotid bruits.
CARDIAC: RR with occasional PVC, 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.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3, CNII-XII intact
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE EXAM:
98.2  105/62  62  18  99%RA
GENERAL: 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 6-7cm.  No carotid bruits.
CARDIAC: RR with occasional PVC, 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.
EXTREMITIES: No c/c/e. No femoral bruits.
NEURO: AAOx3, CNII-XII intact
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+

Pertinent Results:
ADMISSION LABS:
[**2191-3-27**] 03:16PM BLOOD WBC-5.3 RBC-3.55* Hgb-12.2* Hct-36.2*
MCV-102* MCH-34.3* MCHC-33.7 RDW-13.2 Plt Ct-198
[**2191-3-27**] 03:16PM BLOOD PT-11.2 PTT-44.9* INR(PT)-1.0
[**2191-3-27**] 03:16PM BLOOD Glucose-98 UreaN-20 Creat-1.3* Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2191-3-27**] 09:04PM BLOOD CK(CPK)-2123*
[**2191-3-27**] 09:04PM BLOOD CK-MB-GREATER TH cTropnT-8.00*
[**2191-3-28**] 05:55AM BLOOD CK-MB-244* MB Indx-18.4* cTropnT-4.74*
[**2191-3-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 Cholest-220*
[**2191-3-28**] 05:55AM BLOOD Triglyc-107 HDL-68 CHOL/HD-3.2
LDLcalc-131* LDLmeas-148*
[**2191-3-28**] 05:55AM BLOOD %HbA1c-5.6 eAG-114

PERTINENT INTERVAL LABS:
[**2191-3-27**] 09:04PM BLOOD WBC-4.7 RBC-3.41* Hgb-11.4* Hct-35.2*
MCV-103* MCH-33.5* MCHC-32.5 RDW-13.5 Plt Ct-208
[**2191-3-28**] 05:55AM BLOOD WBC-3.8* RBC-3.52* Hgb-12.0* Hct-35.9*
MCV-102* MCH-34.1* MCHC-33.5 RDW-13.3 Plt Ct-199
[**2191-3-29**] 04:33AM BLOOD WBC-3.9* RBC-3.64* Hgb-12.2* Hct-37.3*
MCV-103* MCH-33.5* MCHC-32.7 RDW-13.1 Plt Ct-177
[**2191-3-30**] 04:27AM BLOOD WBC-3.6* RBC-3.90* Hgb-13.3* Hct-40.6
MCV-104* MCH-34.0* MCHC-32.7 RDW-13.2 Plt Ct-205
[**2191-3-28**] 05:55AM BLOOD PT-9.2* PTT-25.3 INR(PT)-0.8*
[**2191-3-27**] 09:04PM BLOOD Glucose-113* UreaN-20 Creat-1.4* Na-138
K-4.7 Cl-104 HCO3-26 AnGap-13
[**2191-3-28**] 05:55AM BLOOD Glucose-91 UreaN-17 Creat-1.2 Na-140
K-4.8 Cl-105 HCO3-25 AnGap-15
[**2191-3-29**] 04:33AM BLOOD Glucose-91 UreaN-19 Creat-1.2 Na-139
K-5.1 Cl-104 HCO3-24 AnGap-16
[**2191-3-30**] 04:27AM BLOOD Glucose-90 UreaN-21* Creat-1.7* Na-137
K-4.6 Cl-101 HCO3-25 AnGap-16
[**2191-3-28**] 05:55AM BLOOD CK(CPK)-1328*
[**2191-3-30**] 04:27AM BLOOD ALT-43* AST-79* LD(LDH)-533* AlkPhos-93
TotBili-0.9
[**2191-3-27**] 09:04PM BLOOD CK-MB-GREATER TH cTropnT-8.00*
[**2191-3-28**] 05:55AM BLOOD CK-MB-244* MB Indx-18.4* cTropnT-4.74*
[**2191-3-27**] 09:04PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3
[**2191-3-28**] 05:55AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1 Cholest-220*
[**2191-3-29**] 04:33AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.7
[**2191-3-30**] 04:27AM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.0 Mg-1.7
[**2191-3-27**] 03:16PM BLOOD TSH-4.0
[**2191-3-28**] 05:55AM BLOOD Triglyc-107 HDL-68 CHOL/HD-3.2
LDLcalc-131* LDLmeas-148*
[**2191-3-28**] 05:55AM BLOOD %HbA1c-5.6 eAG-114

STUDIES:
ECG [**2191-3-27**]: rate 62. Sinus rhythm with a ventricular premature
beat. Inferior ST segment elevation with Q waves suggesting an
inferior myocardial infarction which could be acute. RSR'
pattern in lead V1. Low QRS voltage in the precordial leads. No
previous tracing available for comparison.  TRACING #1

Cardiac Catheterization [**2191-3-27**]:
COMMENTS:
1) Selective angiography of this right-dominant system
demonstrated
significant one-vessel coronary artery disease.  The LMCA had no

angiographically-apparent flow-limiting stenoses.  The LAD had a
50%
mid-vessel stenosis.  The RCA had serial 70% mid- and
distal-vessel
stenoses.  The LCx system had a totally-occluded large obtuse
marginal
branch.
2) Limited resting hemodynamics revealed systemic arterial
hypertension,
with a central aortic pressure of 172/90 mmHg.
ADDENDUM: INTERVENTION COMMENTS:
Initial angiography revealed an occlusion of OM which we planned
to
treat with PTCA and stenting. A 6 Fr XB 3.0 guiding catheter
provided
good support throughout the procedure. Bivalirudin bolus was
administered and infusion started. A Prowater wire was used to
successfully cross the occlusion and was positioned in the
distal
vessel. An Apex OTW 2.0 x 8 mm balloon was used to pre-dilate
the
lesion, restoring flow to the vessel. This was then stented
using an
Integrity 3.0 x 22 mm bare metal stent deployed at 18 atm. Final

angiography revealed an excellent result with 0% residual
stenosis in
the stented segment, TIMI 3 flow within the vessel and no
apparent
dissection. Hemostasis achieved at the right femoral arterial
access
site using Angioseal vascular closure device.
FINAL DIAGNOSIS:
1. Significant one-vessel coronary artery disease.
2. Primary PCI of obtuse marginal occlusion with bare metal
stent.
.
ECHO [**2191-3-28**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the basal half of the basal half of the inferior and
inferolateral walls. The remaining segments contract well (LVEF
50%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is an anterior fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional systolic dysfunction c/w CAD
(PDA distribution).


Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Mr. [**Known lastname 101177**] is a 59M h/o hypothyroidism and unspecified MSK
disease (per pt, is lupus), p/w classic ACS symptoms, found to
have a STEMI, s/p BMS to OM1.

ISSUES:
# STEMI: Patient presented with classic ACS symptoms, including
substernal chest pressure, arm and jaw pain. Patient had a
demonstrable STEMI, culprit lesion is OM1 s/p BMS PCI. He
remained hemodynamically stable throughout hospitalization. He
has had a few occasional runs of PVC's on telemetry, no other
complications. The patient was discharged on aspirin, plavix,
atorvastatin 80mg, metoprolol succinate 50mg qd. Lisinopril was
held because of [**Last Name (un) **].  The patient was discharged to home with
PCP [**Name9 (PRE) 702**] and cardiology follow-up, and was recommended to
pursue cardiac rehab.

# [**Last Name (un) **]: Admission Cr 1.3.  Cr increased to 1.7 on [**2191-3-30**] (from
1.2), likely secondary to dye load from catheterization. The
patient was urged to drink plenty of fluids.  The patient was
very anxious to be discharged, so we sent patient with a
prescription to have chem 7 checked tomorrow at his PCP's
office.  We held his lisinopril in the setting of worsening
renal function.
.
#  Hypothyroidism: continue home levothyroxine
.
#  Unspecified MSK Dx (per pt, is lupus involving b/l hand
joints, and he has been taking 5mg prednisone qd-[**Hospital1 **] for 1 month
PTA). We held the patient's prednisone throughout his hospital
course.
.
TRANSITIONS OF CARE:
- repeat lipid panel as outpatient to ensure LDL at goal
- start lisinopril when Cr normalizes

Medications on Admission:
HOME MEDICATIONS:
Prednisone 10mg daily for past month
Levothyroxine, unknown dose
.

Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
6. Outpatient Lab Work
ICD-9 code: acute kidney injury
Check Chem 7 panel on [**2191-3-31**]
Please fax results: [**Last Name (LF) **],[**First Name3 (LF) **] B.
[**Hospital3 **] MEDICINE
Phone: [**Telephone/Fax (1) 4475**] / Fax: [**Telephone/Fax (1) 29683**]


Discharge Disposition:
Home

Discharge Diagnosis:
ST- elevated myocardial infarction


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted to the [**Hospital1 18**] for chest pain.  You were found
to have a heart attack.  You had a bare metal stent placed in
one of your coronary arteries.  It is very important for you to
follow up with your new cardiologist and your primary care
physician.

You also had some kidney injury while you were in the hospital.
It is very important that you drink plenty of water at home and
you need to have a laboratory test tomorrow to evaluate your
renal function.

If you have any chest pain, shortness of breath or any other
symptoms that worry you, you should call your PCP or present to
the emergency department as soon as possible.

Continue to take all of your medications as you previously had,
EXCEPT:
ADD aspirin  325 mg Tablet, Delayed Release (E.C.)  Sig:  One
(1) Tablet, Delayed Release (E.C.) by mouth DAILY (Daily).

ADD clopidogrel  75 mg Tablet  Sig:  One (1) Tablet by mouth
once a day.

ADD atorvastatin  80 mg Tablet  Sig:  One (1) Tablet by mouth
DAILY (Daily).

ADD Toprol XL  50 mg Tablet Extended Release 24 hr  Sig:  One
(1) Tablet Extended Release 24 hr by mouth once a day.

ADD levothyroxine  50 mcg Tablet  Sig:  One (1) Tablet by mouth
DAILY

Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 101180**], MD
When: Wednesday [**4-6**] at 3:15pm
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]

Name: [**Doctor First Name **] [**First Name8 (NamePattern2) **]  [**Name8 (MD) **],  MD
Specialty: Cardiology
When: Thursday [**4-14**] at 1:45pm
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
{'Acute myocardial infarction of unspecified site, initial episode of care,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other specified inflammatory polyarthropathies,Unspecified acquired hypothyroidism,Other specified cardiac dysrhythmias'}


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: STEMI

PRESENT ILLNESS: Mr. [**Known lastname 101177**] is a 59M letter carrier who was working the night
shift when he had chest pressure, b/l jaw pain, diaphoresis, and
nausea. He went to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 101178**] where he had an EKG that
showed II>III STE. No RV or posterior leads were started. A
nitro gtt was briefly started but discontinued abruptly prior to
transfer at the reccomendations of our cardiology fellow. He was
given ASA, Plavix load, G32B inhibitor and heparin. He had some
bradycardia to the 30's. He was transferred to [**Hospital1 18**] cath lab
for urgent intervention.
.
He was found to have 100% occlusion of large OM1. A BMS was
deployed with some mild STE without chest pain felt to be
reperfusuion. He is currently CP free. He did get bivalirudin
during the case.  On the CCU, he says he feels "great" and
denies CP, HA, SOB, abdom pain, chest pressure. At baseline, he
does cardio exercise 3-4x/wk doing stairmaster or spinning

MEDICAL HISTORY: ??Inflammatory arthritis (lupus per pt)
[**Name (NI) 101179**]

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Prednisone 10mg daily for past month
Levothyroxine, unknown dose
.

ALLERGIES: Tapazole

PHYSICAL EXAM: ADMISSION EXAM:
GENERAL: 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: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother:  still alive, no cardiac Hx
- Father:  still alive at 83, had CABG in 60s

SOCIAL HISTORY: The patient works in the post office.  No tobacco use since
early [**2158**].  No alcohol use. 

### Response:
{'Acute myocardial infarction of unspecified site, initial episode of care,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Other specified inflammatory polyarthropathies,Unspecified acquired hypothyroidism,Other specified cardiac dysrhythmias'}
