CHIEF COMPLAINT: Chest pain.

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with hypertension and hypothyroidism who presents with
fatigue and dyspnea on exertion after taking down his
with rest occurring the day prior to admission.  The patient
denied any nausea, vomiting, chest pain, or diaphoresis
associated with these symptoms.  There is no history of
orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  The
patient states that he has never had chest pain before but
has had what he calls an ache in his chest along with
headache and abdominal cramps as part of his polymyalgia

MEDICAL HISTORY: 1.  Polymyalgia rheumatica, on steroids for the last seven
years.
2.  Hypothyroidism.
3.  Hypertension.
4.  Macular degeneration.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Daughter with lung CA.  No history of CAD in
any immediate family members.

SOCIAL HISTORY: Tobacco, quit 35 years ago, 40 pack year
history.  No alcohol use.
Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified essential hypertension
Subendo infarct, initial,Crnry athrscl natve vssl,Accidental op laceration,Urin tract infection NOS,Chr blood loss anemia,Gastrointest hemorr NOS,Polymyalgia rheumatica,Hypothyroidism NOS,Hypertension NOS
Admission Date:  [**2109-2-14**]       Discharge Date:  [**2109-2-20**]


Service:  CCU
CHIEF COMPLAINT:  Chest pain.

HISTORY OF THE PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
male with hypertension and hypothyroidism who presents with
fatigue and dyspnea on exertion after taking down his
with rest occurring the day prior to admission.  The patient
denied any nausea, vomiting, chest pain, or diaphoresis
associated with these symptoms.  There is no history of
orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  The
patient states that he has never had chest pain before but
has had what he calls an ache in his chest along with
headache and abdominal cramps as part of his polymyalgia

PAST MEDICAL HISTORY:
1.  Polymyalgia rheumatica, on steroids for the last seven
years.
2.  Hypothyroidism.
3.  Hypertension.
4.  Macular degeneration.

ALLERGIES:  The patient has no known drug allergies.

ADMISSION MEDICATIONS:
1.  Aspirin.
2.  Vasotec 10 mg p.o. q.d.
3.  Zantac 150 mg p.o. b.i.d.
4.  Atenolol 25 mg p.o. q.d.
5.  Levoxyl 50 micrograms p.o. q.d.
6.  Prednisone 10 mg p.o. q.d. for the last seven years.

SOCIAL HISTORY:  Tobacco, quit 35 years ago, 40 pack year
history.  No alcohol use.

FAMILY HISTORY:  Daughter with lung CA.  No history of CAD in
any immediate family members.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Temperature
97.3, blood pressure 150/80, pulse 76, respiratory rate 24,
02 saturation 96% on room air.  HEENT:  The pupils were
equal, round, and reactive to light and accommodation.  The
mucous membranes were moist.  The oropharynx was clear.
There was no jugular venous distention.  Cardiovascular:
Regular rate and rhythm, normal S1, S2.  The lungs were clear
to auscultation bilaterally.  Neck:  Supple.  No JVD, no
lymphadenopathy.  No carotid bruits.  Abdomen:  Soft,
nontender, nondistended, normoactive bowel sounds.
Extremities:  No cyanosis, clubbing, 2+ DP pulses.  No
femoral bruits.  There was 1+ pitting edema to the knees
bilaterally.  There was diffuse bruising on the bilateral
upper extremities.

LABORATORY DATA ON ADMISSION:  White blood count 13.8,
hematocrit 40.0, platelets 280,000.  Sodium 144, potassium
4.4, chloride 105, bicarbonate 25, BUN 31, creatinine 1.3.
INR 1.0, PTT 21.4, PT 12.1, ESR 13.  CK number one 645 with
an MB of 109.  Troponin greater than 50.  Lipid panel:
Cholesterol total of 207, LDL 116, triglycerides 111, HDL 69.

Chest x-ray revealed no acute cardiopulmonary process.

EKG revealed a normal sinus rhythm at 55, LAD, increased QT
intervals, 0.[**Street Address(2) 1755**] depression in I and aVL, [**Street Address(2) 4793**]
depression in V4 through V6 with T wave inversions in V2 and
V3.

IMPRESSION:  The patient is a [**Age over 90 **]-year-old male with
hypertension, history of tobacco use who presents with
anterolateral non ST elevation myocardial infarction.

HOSPITAL COURSE:
1. CARDIOVASCULAR:  The patient was initially started on
heparin and nitroglycerin drips, metoprolol 25 mg p.o.
t.i.d., continued on ACE inhibitor, aspirin, statin, and was
taken to the cardiac catheterization laboratory on [**2109-2-15**].

At catheterization, he was found to have severe three vessel
disease which was discussed with the Cardiothoracic Surgery
Team and as the patient was felt to be a poor surgical
candidate given his chronic steroid use as well as his age,
it was felt that medical maximization would be pursued as
well as potentially intervening on the coronary lesions.

During the interventional portion of the catheterization, the
LAD was stented with 0% residual stenosis.  There was a
dissection in the process of catheterization and the left
main dissected into the ascending aorta.  This was corrected
with a stent placed in the left main artery with 20% residual
stenosis.

Other findings on catheterization included an 80% left
circumflex lesion at the origin and proximal disease.  The
right coronary was 79-90% lesion with collaterals from the
LAD.  During catheterization, the patient was becoming
significantly more agitated and was given a heavy amount of
sedation and intubated for airway protection.

The patient underwent a transesophageal echocardiogram to
determine the extent of the dissection of the aorta.  TE
revealed a dissection in the proximal ascending aorta which
did not extend beyond the coronary cusp and the patient was
admitted to the Cardiac Care Unit for further intensive
monitoring.

On transfer to the CCU, the patient was noted to be becoming
more hypotensive and an arterial line was placed for closer
monitoring of blood pressure and a central line was placed in
the left subclavian vein after multiple attempts at central
access in the right IJ and right subclavian veins.  The
patient was briefly started on dopamine for pressor support
which was discontinued after only being on it for several
minutes.

The patient was noted to have a significant amount of
hematemesis and the hypotension was attributed largely to
blood loss as well as sedation effect.  There was possibly
also a contributing factor of chronic steroid use with
relative adrenal insufficiency.

From a coronary standpoint, there was no further evidence of
ischemia or further hypotension the following morning and the
patient was extubated without complications and started on a
beta blocker as well as an ACE inhibitor.  TEE had
demonstrated significant LV dysfunction and the patient was
noted to be wet on lung examination.  He was started on
increasing doses of ACE inhibitor and was diuresed with one
dose of Lasix.

From a rhythm standpoint, the patient was noted to have one
episode of nonsustained ventricular tachycardia with four
beats with no other significant ectopy and will be continued
on a beta blocker as an outpatient with no further workup as
far as an EP study given the patient's age and chronic
steroid use.

2.  GASTROINTESTINAL:  The patient was noted to have
hematemesis post TEE which was felt to be likely due to
traumatic transesophageal echocardiogram.  He was lavaged
with an OG tube which showed clearing after only 200-300 cc
of lavaged fluid.  While on suction, the lavage fluid turned
pink and then began to have blood in it again.  He was
lavaged with 50 cc and it again cleared.  As a result, the
patient was transfused 2 units of packed red blood cells and
had a stable hematocrit after this point.

The Gastroenterology Service was consulted and agreed that
likely this was a bleed in the setting of the transesophageal
echocardiogram.  The OG tube was recommended to be
discontinued and hematocrits were to be followed as well as
hemodynamics.  There was no further evidence of bleeding
either by hematocrit or by hemodynamic monitoring and the
patient continues to be stable at the time of discharge.

3.  ENDOCRINE:  The patient has a history of chronic steroid
use and was given stress-dose steroids while in the Intensive
Care Unit which were rapidly tapered from 100 mg t.i.d. of
hydrocortisone to 50 mg of prednisone to 30 mg of prednisone
and now back to his 10 mg outpatient dose of prednisone with
no evidence from a pressure standpoint of adrenal
insufficiency and no evidence of electrolyte abnormalities as
the result of the steroids.

4.  PLASTICS:  While the patient was agitated, he was briefly
restrained when trying to remove his endotracheal tube and in
the process the skin on his hand peeled due to easy
friability from chronic steroid use.  Plastic Surgery was
consulted and sutured the laceration on the right hand.  They
recommended continuing dressing changes q.d. which will be
done by the visiting nurse.  The patient is to follow-up in
the Hand Clinic in two weeks for suture removal and wound
check.  The number for the [**Hospital 3595**] Clinic was given to the
patient.  This was discussed with his family who will set up
an appointment in two weeks for the hand clinic.

5.  PULMONARY:  The patient was briefly intubated for airway
protection due to agitation and sedation.  He was extubated
the following morning after checking his settings on pressure
support and having adequate ventilation and oxygenation.  The
tube was removed.  The patient was oxygenating well on his
own postextubation.

6.  INFECTIOUS DISEASE:  The patient was noted to have a
urinary tract infection likely due to Foley placement and was
treated with a seven day course of levofloxacin which he is
to continue as an outpatient for the next three days post
discharge.

DISCHARGE DIAGNOSIS:
1.  Acute myocardial infarction.
2.  Status post left main dissection.
3.  Status post left main and left anterior descending artery
stenting.
4.  Status post upper gastrointestinal bleed.
5.  Hypothyroidism.
6.  Polymyalgia rheumatica.

DISCHARGE CONDITION:  Good.  The patient was seen by Physical
Therapy and was felt to be walking well on his own and will
be continued to be followed as an outpatient with home PT as
well as visiting nursing for dressing changes and
medications.  The patient is to follow-up with the Hand
Clinic in two weeks as well as his primary care physician,
[**Last Name (NamePattern4) **]. ....................< in the next week to two weeks.

DISCHARGE MEDICATIONS:
1.  Toprol XL 100 mg p.o. q.d.
2.  Imdur 30 mg p.o. q.d.
3.  Lisinopril 10 mg p.o. q.d.
4.  Aspirin 325 mg p.o. q.d.
5.  Prednisone 10 mg p.o. q.d.
6.  Plavix 75 mg p.o. q.d.
7.  Lipitor 20 mg p.o. q.d.
8.  Synthroid 50 micrograms p.o. q.d.
9.  Levofloxacin 250 mg p.o. q.d. for the next three days.
10. Zantac 150 mg p.o. b.i.d.
11. Quinine 260 mg p.o. q.d.




                            [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7169**]

Dictated By:[**Name8 (MD) 4630**]
MEDQUIST36

D:  [**2109-2-20**]  02:17
T:  [**2109-2-20**]  14:22
JOB#:  [**Job Number 93705**]
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified essential hypertension'}


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: The patient is a [**Age over 90 **]-year-old
male with hypertension and hypothyroidism who presents with
fatigue and dyspnea on exertion after taking down his
with rest occurring the day prior to admission.  The patient
denied any nausea, vomiting, chest pain, or diaphoresis
associated with these symptoms.  There is no history of
orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  The
patient states that he has never had chest pain before but
has had what he calls an ache in his chest along with
headache and abdominal cramps as part of his polymyalgia

MEDICAL HISTORY: 1.  Polymyalgia rheumatica, on steroids for the last seven
years.
2.  Hypothyroidism.
3.  Hypertension.
4.  Macular degeneration.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Daughter with lung CA.  No history of CAD in
any immediate family members.

SOCIAL HISTORY: Tobacco, quit 35 years ago, 40 pack year
history.  No alcohol use. 

### Response:
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Urinary tract infection, site not specified,Iron deficiency anemia secondary to blood loss (chronic),Hemorrhage of gastrointestinal tract, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified essential hypertension'}
