CHIEF COMPLAINT: Chest pain, non ST elevation myocardial
infarction.

PRESENT ILLNESS: This is an 83 year old female
with a history of hypertension, who presented to outside
hospital on [**2103-5-10**], with a two day history of right sided
chest pain radiating to the scapula.  She had been having
about two weeks of progressive exertional chest pain and
dyspnea on exertion without radiation or associated symptoms
and resolving with rest.  The patient's initial
electrocardiogram at outside hospital showed no ST elevations
but questionable Q waves in V1 through V3.  She was noted to
have a troponin I leak with peak of 0.2 with flat CKs.  Chest
x-ray at that time was consistent with congestive heart
failure and BNP measured was 2710.  The patient was started
on Aspirin/Heparin/beta blocker and plan was to transfer to
[**Hospital1 69**] for catheterization.
Events that occurred after initial evaluation at outside
hospital included a dropping hematocrit from 30.7 to 25.2.
The patient was guaiac negative.  She received a total of
four units of packed red blood cells with a rise in her
hematocrit to 36.0 to 37.0.  The Heparin drip was stopped.
She had recurrent anginal episodes without ST segment changes
with another troponin I leak and peak at 0.11 and new T wave
inversions in V2 through V6.  Her Heparin drip was restarted
at that time.  The patient was diuresed with Lasix
aggressively for congestive heart failure with creatinine
rising to 2.3 from baseline of 1.6.  Given this rise and
inadequate diuresis, the patient was started on Nesiritide.
On [**2103-5-13**], the patient complained of chest pain radiating
to the back and had CTA which ruled out dissection and
abdominal aortic aneurysm but showed bilateral lung effusions
which were small.  The patient also received transthoracic
echocardiogram on [**2103-5-11**], at outside hospital which by
report showed ejection fraction of 25 to 30% with anterior,
inferior, and apical akinesis, and moderate tricuspid
regurgitation and mitral regurgitation.  By report, she also
had a urinary tract infection on transfer and received one
dose of Levofloxacin.  On catheterization at outside
hospital, she had three vessel disease reportedly left
anterior descending 90%, left circumflex 80%, right coronary
artery 90% stenoses and transferred to [**Hospital1 190**] for consideration for coronary artery bypass
graft.  On arrival, she denied chest pain, shortness of
breath, fevers, chills, nausea, vomiting, diarrhea, lower
extremity edema and weight loss or weight gain recently.

MEDICAL HISTORY: 1.  Hypertension.
2.  Anemia on weekly B12 shots.
3.  Depression.
4.  Status post appendectomy and total abdominal
hysterectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of myocardial infarction at
unknown age.

SOCIAL HISTORY: The patient lives alone and attends elderly
DayCare five times a week.  She denies tobacco, ETOH or
intravenous drug use and reports supportive family ([**Female First Name (un) **]
telephone [**Telephone/Fax (1) 55090**] who helps the patient make health
care decisions).
Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Paroxysmal ventricular tachycardia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified
Subendo infarct, initial,CHF NOS,Parox ventric tachycard,Thrombocytopenia NOS,Acute kidney failure NOS,Hyp kid NOS w cr kid V,Urin tract infection NOS,Crnry athrscl natve vssl,Anemia NOS
Admission Date:  [**2103-5-17**]       Discharge Date:  [**2103-5-28**]


Service:

ADDENDUM - DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Coronary artery disease.
3. Hypertension.
4. Anemia.
5. Depression.

DISCHARGE MEDICATIONS:
1. Coated aspirin 325 mg po qd.
2. Plavix 75 mg po qd.
3. Atorvastatin 80 mg po qd.
4. Metoprolol XL 25 mg po qd.
5. Valsartan 160 mg po qd.
6. Amlodipine 5 mg po qd.
7. Sublingual Nitroglycerin 0.3 mg po q 5 min, up to 3
tablets, prn angina.
8. Sertraline.
9. Vitamin B12 50 mcg po qd.
10.Calcium acetate 667 mg po tid with meals.
11.Calcium carbonate 600 mg po bid in between meals.
12.Vitamin 400 U po qd.
13.Colace 100 mg po bid prn constipation.
14.Bisacodyl 10 mg po qd prn constipation.
15.Coumadin 2.5 mg po q hs.

FOLLOW-UP PLANS:
1. Have spoken with Dr. [**Last Name (STitle) 51717**], patient's primary
care physician, [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3658**], to follow-up with patient
regarding INR levels in next few days.  The patient will call
for an appointment.
2. She will also follow-up with Dr. [**Last Name (STitle) 1295**] in [**Location (un) 47**] in
the next 3-4 weeks for cardiology.




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36

D:  [**2103-5-28**]  09:24
T:  [**2103-5-28**]  09:32
JOB#:  [**Job Number 55011**]


Admission Date:  [**2103-5-17**]       Discharge Date:  [**2103-5-28**]


Service:  CCU

CHIEF COMPLAINT:  Chest pain, non ST elevation myocardial
infarction.

HISTORY OF PRESENT ILLNESS:  This is an 83 year old female
with a history of hypertension, who presented to outside
hospital on [**2103-5-10**], with a two day history of right sided
chest pain radiating to the scapula.  She had been having
about two weeks of progressive exertional chest pain and
dyspnea on exertion without radiation or associated symptoms
and resolving with rest.  The patient's initial
electrocardiogram at outside hospital showed no ST elevations
but questionable Q waves in V1 through V3.  She was noted to
have a troponin I leak with peak of 0.2 with flat CKs.  Chest
x-ray at that time was consistent with congestive heart
failure and BNP measured was 2710.  The patient was started
on Aspirin/Heparin/beta blocker and plan was to transfer to
[**Hospital1 69**] for catheterization.
Events that occurred after initial evaluation at outside
hospital included a dropping hematocrit from 30.7 to 25.2.
The patient was guaiac negative.  She received a total of
four units of packed red blood cells with a rise in her
hematocrit to 36.0 to 37.0.  The Heparin drip was stopped.
She had recurrent anginal episodes without ST segment changes
with another troponin I leak and peak at 0.11 and new T wave
inversions in V2 through V6.  Her Heparin drip was restarted
at that time.  The patient was diuresed with Lasix
aggressively for congestive heart failure with creatinine
rising to 2.3 from baseline of 1.6.  Given this rise and
inadequate diuresis, the patient was started on Nesiritide.
On [**2103-5-13**], the patient complained of chest pain radiating
to the back and had CTA which ruled out dissection and
abdominal aortic aneurysm but showed bilateral lung effusions
which were small.  The patient also received transthoracic
echocardiogram on [**2103-5-11**], at outside hospital which by
report showed ejection fraction of 25 to 30% with anterior,
inferior, and apical akinesis, and moderate tricuspid
regurgitation and mitral regurgitation.  By report, she also
had a urinary tract infection on transfer and received one
dose of Levofloxacin.  On catheterization at outside
hospital, she had three vessel disease reportedly left
anterior descending 90%, left circumflex 80%, right coronary
artery 90% stenoses and transferred to [**Hospital1 190**] for consideration for coronary artery bypass
graft.  On arrival, she denied chest pain, shortness of
breath, fevers, chills, nausea, vomiting, diarrhea, lower
extremity edema and weight loss or weight gain recently.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Anemia on weekly B12 shots.
3.  Depression.
4.  Status post appendectomy and total abdominal
hysterectomy.

MEDICATIONS ON TRANSFER:
1.  Zocor 40 mg p.o. once daily.
2.  Zoloft 100 mg p.o. once daily.
3.  TUMS 600 mg p.o. twice a day.
4.  Aspirin 81 mg p.o. once daily.
5.  Protonix 40 mg p.o. once daily.
6.  Metoprolol 2.5 mg p.o. three times a day.
7.  Diovan 160 mg p.o. once daily.
8.  Norvasc 5 mg p.o. once daily.
9.  Hydrochlorothiazide 12.5 mg p.o. once daily.
10. Epogen 10k three times a week.
11. Heparin drip.
12. Nesiritide drip.
13. Nitroglycerin drip.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Father died of myocardial infarction at
unknown age.

SOCIAL HISTORY:  The patient lives alone and attends elderly
DayCare five times a week.  She denies tobacco, ETOH or
intravenous drug use and reports supportive family ([**Female First Name (un) **]
telephone [**Telephone/Fax (1) 55090**] who helps the patient make health
care decisions).

PHYSICAL EXAMINATION:  On admission, vital signs revealed
temperature 99.8, blood pressure 146/44, pulse 57,
respiratory rate 20, oxygen saturation 94% in room air.  The
patient weighed 63.6 kilograms.  In general, an elderly
female, hard of hearing, in no acute distress.  Head, eyes,
ears, nose and throat examination - Small but reactive and
equal pupils bilaterally.  The oropharynx is clear.  Mucous
membranes are very dry.  Cardiovascular - bradycardic,
regular rate and rhythm, normal S1 and S2, II/VI systolic
murmur loudest at the right upper sternal border.  Lungs
revealed rales at bilateral bases, right greater than left,
and otherwise clear anteriorly.  The abdomen revealed
normoactive bowel sounds, soft, nontender, nondistended.  No
groin bruits.  Right venous and arterial sheaths in place.
Extremities - trace to 1+ bilateral lower extremity edema to
the knees, 2+ dorsalis pedis pulses bilaterally, warm and
well perfused.

LABORATORY DATA:  On admission laboratory data was
significant for laboratories from outside hospital showing
hematocrit 37.2, creatinine 1.6, partial thromboplastin time
41.2.  Urinalysis showed positive nitrites, large leukocyte
esterase, 90-100 white blood cells, many bacteria, greater
than 100,000 gram negative rods.  Troponin I peak at 0.11.
CK peak at 110.

HOSPITAL COURSE:
1.  Coronary artery disease - Status post non ST elevation
myocardial infarction - The patient was evaluated by CT
surgery here and catheterization films reviewed by cardiology
and CT surgery staff.  She was deemed to be a poor surgical
candidate and given discrete lesions on angiography it was
determined to have her left anterior descending stented.
While awaiting to have her stent placed, secondary to
elevated creatinine, and debates as to surgery versus PCI,
the patient developed recurrent episodes of chest pain
associated with 2.[**Street Address(2) 2811**] elevations in V2 through
V3, 1.[**Street Address(2) 2811**] elevations in V1 and V4, and upright T
waves in leads II and III with T wave flattening across the
precordium.  Her baseline electrocardiogram on arrival had
been notable for deep T wave inversions in the precordial
leads.  Each of these episodes of chest pain was in the
setting of the patient being hypertensive to systolic blood
pressure of 180s to 190s and tachycardic to low 100s.  The
patient responded each time to aggressive blood pressure
lowering with beta blockade, increasing Nitroglycerin drip,
sublingual Nitroglycerin times three, Hydralazine and
Magnesium Sulfate.  After resolution of chest pain,
electrocardiogram noted to revert to prior with deep T wave
inversions across the precordium.  It appears that
hypertension and tachycardia were directly related and
resulted from chest pain rather than preceding it.  The
patient had intra-aortic balloon pump placed to increase
coronary perfusion given tight left anterior descending
stenosis and recurrent chest pain and was started on Heparin
and Integrilin.  She was noted the next day to have nosebleed
and groin bleed secondary to supertherapeutic Integrilin and
these drips were then held.  On [**2103-5-23**], the patient had
successful placement of 3.0 times 12 millimeter Taxus drug
eluting stent in proximal left anterior descending.  Several
hours afterward, she complained of vague chest/left
shoulder/back pain not associated with hypertension or
tachycardia.  Her hematocrit was rechecked and noted to be
stable and groin sites intact without abdominal or lower back
pain, suggesting no retroperitoneal bleed.  Her
electrocardiograms were unchanged at this time, suggesting
her pain was not cardiac in nature.  She was relieved with
Morphine and this pain did not recur.  On discharge, she will
be medically managed with daily Aspirin, Plavix, and Toprol
at low dose limited by bradycardia, statin and [**Last Name (un) **] added at
low dose.

2.  Congestive heart failure - The patient with ejection
fraction of 25 to 30% noted on recent transthoracic
echocardiogram with apical akinesis.  She was aggressively
diuresed at outside hospital and appeared quite dry on
admission.  We aimed to have the patient euvolemic to
slightly negative initially and maintain good p.o. intake for
the remainder of her admission given likely overdiuresis.
She maintained good oxygen saturation.  We started her on
Coumadin given apical akinesis and the patient will follow-up
with primary care physician for INR levels as an outpatient.
Her bibasilar crackles did not seem to change throughout her
admission despite initial diuresis.

3.  Rhythm - The patient continued in sinus bradycardia with
one episode of nonsustained ventricular tachycardia of three
beats only.

4.  Hypertension - We initially increased Diovan to 240 mg a
day for control of blood pressure as increase of beta blocker
limited by bradycardia.  However, creatinine began to rise,
also perhaps secondary to catheterization dye.  Thus, Diovan
was stopped and Hydralazine and Norvasc initiated for blood
pressure control as unclear if this may have contributed to
recurrent demand ischemia and chest pain.  On discharge, we
have restarted low dose of [**Last Name (un) **] as creatinine decreasing and
stopped Hydralazine.  We will aim to stop Amlodipine as well.
The patient had renal ultrasound to rule out renal artery
stenosis given large episodic increases suddenly in blood
pressure though these were associated with chest pain.  She
had slightly atrophic kidneys bilaterally but no evidence of
renal artery stenosis.

5.  Acute on chronic renal failure - Unclear reason of
baseline chronic renal failure.  Creatinine here peaked at
2.4 likely secondary to prerenal cause and contrast dye
induced nephropathy.  She did receive several doses of
Mucomyst periprocedure.  Creatinine appears to be trending
down and we are allowing the patient to take p.o. freely and
maintain euvolemia on her own.  Creatinine should be
monitored as an outpatient as [**Last Name (un) **] is being restarted.

6.  Urinary tract infection - The patient was treated with
Levofloxacin which was given daily though ordered to be
q.o.d.  She thus received a shorter though likely
supertherapeutic course given impaired creatinine clearance.
She had no further dysuria during admission.

7.  Hematology - The patient with thrombocytopenia noted
after intra-aortic balloon pump placed, improving after
removal.  Likely was secondary to destruction from
intra-aortic balloon pump.  Anemia - We continued p.o.
Vitamin B12.  The patient may resume shots if needed as an
outpatient.  Hematocrit remained stable throughout
hospitalization.

8.  Depression - Continued Sertraline.

9.  Prophylaxis - Heparin drip, subcutaneous Heparin while on
bedrest, with bowel regimen.  Ambulation once the patient had
recovered.

10. Fluids, electrolytes and nutrition - Cardiac diet and
repleted electrolytes p.r.n.  Allowed the patient to remain
euvolemic.

11. Disposition - The patient worked with physical therapy
who deemed her rehabilitation candidate.  She has been
screened and accepted by [**Hospital 21585**] [**Hospital **] Hospital.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  To rehabilitation.

DISCHARGE DIAGNOSES:




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36

D:  [**2103-5-27**]  13:13
T:  [**2103-5-27**]  14:38
JOB#:  [**Job Number 55091**]
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Paroxysmal ventricular tachycardia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified'}


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, non ST elevation myocardial
infarction.

PRESENT ILLNESS: This is an 83 year old female
with a history of hypertension, who presented to outside
hospital on [**2103-5-10**], with a two day history of right sided
chest pain radiating to the scapula.  She had been having
about two weeks of progressive exertional chest pain and
dyspnea on exertion without radiation or associated symptoms
and resolving with rest.  The patient's initial
electrocardiogram at outside hospital showed no ST elevations
but questionable Q waves in V1 through V3.  She was noted to
have a troponin I leak with peak of 0.2 with flat CKs.  Chest
x-ray at that time was consistent with congestive heart
failure and BNP measured was 2710.  The patient was started
on Aspirin/Heparin/beta blocker and plan was to transfer to
[**Hospital1 69**] for catheterization.
Events that occurred after initial evaluation at outside
hospital included a dropping hematocrit from 30.7 to 25.2.
The patient was guaiac negative.  She received a total of
four units of packed red blood cells with a rise in her
hematocrit to 36.0 to 37.0.  The Heparin drip was stopped.
She had recurrent anginal episodes without ST segment changes
with another troponin I leak and peak at 0.11 and new T wave
inversions in V2 through V6.  Her Heparin drip was restarted
at that time.  The patient was diuresed with Lasix
aggressively for congestive heart failure with creatinine
rising to 2.3 from baseline of 1.6.  Given this rise and
inadequate diuresis, the patient was started on Nesiritide.
On [**2103-5-13**], the patient complained of chest pain radiating
to the back and had CTA which ruled out dissection and
abdominal aortic aneurysm but showed bilateral lung effusions
which were small.  The patient also received transthoracic
echocardiogram on [**2103-5-11**], at outside hospital which by
report showed ejection fraction of 25 to 30% with anterior,
inferior, and apical akinesis, and moderate tricuspid
regurgitation and mitral regurgitation.  By report, she also
had a urinary tract infection on transfer and received one
dose of Levofloxacin.  On catheterization at outside
hospital, she had three vessel disease reportedly left
anterior descending 90%, left circumflex 80%, right coronary
artery 90% stenoses and transferred to [**Hospital1 190**] for consideration for coronary artery bypass
graft.  On arrival, she denied chest pain, shortness of
breath, fevers, chills, nausea, vomiting, diarrhea, lower
extremity edema and weight loss or weight gain recently.

MEDICAL HISTORY: 1.  Hypertension.
2.  Anemia on weekly B12 shots.
3.  Depression.
4.  Status post appendectomy and total abdominal
hysterectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Father died of myocardial infarction at
unknown age.

SOCIAL HISTORY: The patient lives alone and attends elderly
DayCare five times a week.  She denies tobacco, ETOH or
intravenous drug use and reports supportive family ([**Female First Name (un) **]
telephone [**Telephone/Fax (1) 55090**] who helps the patient make health
care decisions). 

### Response:
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Paroxysmal ventricular tachycardia,Thrombocytopenia, unspecified,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Coronary atherosclerosis of native coronary artery,Anemia, unspecified'}
