CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: Pt is a 54 y/o man w/ a PMH significant for HTN who developed
substernal chest pressure while working outside in his yard.  He
went inside and lay down on the floor in front of the fan where
he was found by his wife.  She called EMS and he denied fall or
LOC when they arrived.  He received aspirin, nitro, and NS and
was transfered to the [**Hospital3 3583**].  In [**Hospital1 46**], he was
hypertensive to 164/118 and bradycardic to 42.  His EKG was
significant for complete heart block with ST elevations in II,
III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2.
He was started on heparin, aggrastat, asa and morphine prior to
being transfered to [**Hospital1 18**].  Of note, his wife said that he has
developed mild pedal edema over the past few days and states
that his exercise tolerance has dropped recently.
.
In the cath lab, he was seen to be actuely vagal with
hypotension and emesis.  He was also acutely acidotic and
hypoxic.  He was intubated for airway protection.  An
intra-aortic balloon pump was placed secondary to his
hypotension.  He had several episodes of VT that aborted with
amiodarone 150mg bolus and lidocaine 75mg bolus.  He was started
on an amiodarone drip.  His cath demonstrated a totally occluded
mid-RCA that was stented.  His RPL was ballooned.  His right
sided filling pressures were elevated with a PCW 37, RA 27, RV
62/18, and PA 62/38.  He had no step up.  He received 80mg of
lasix in the lab.

MEDICAL HISTORY: HTN
asthma
lumbar disc herniation

MEDICATION ON ADMISSION: Univasc
primatene mist

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Pt intubated and sedated with an OG tube
HEENT: PERRL
Neck: -LAD
CV: RRR, s1/s2 intact, -M/G/R
Lungs: Coarse breath sounds b/l
Abd: S/NT/ND, + BS
Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B
Ext: -C/C/E, palpable LE pulses b/l

FAMILY HISTORY: father died at 49 from MI and  mother w/ cardiac issues "at
birth" and died at 49 from "cardiac issues". siblings w/out
medical issues

SOCIAL HISTORY: no smoking, social alcohol, no ivdu.  lives w/ wife and
daughter.
Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Conduction disorder, unspecified,Asthma, unspecified type, unspecified,Displacement of lumbar intervertebral disc without myelopathy
AMI inferopost, initial,Cardiogenic shock,CHF NOS,Acute respiratry failure,Acute kidney failure NOS,Food/vomit pneumonitis,Hematoma complic proc,Crnry athrscl natve vssl,Atrial fibrillation,Hypertension NOS,Chr pulmon heart dis NEC,Conduction disorder NOS,Asthma NOS,Lumbar disc displacement
Admission Date:  [**2178-8-29**]              Discharge Date:   [**2178-9-7**]

Date of Birth:  [**2124-1-8**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
Cardiac catheterization
Aortic balloon pump insertion
arterial line placement
intubation
swan-ganz catheter placement

History of Present Illness:
Pt is a 54 y/o man w/ a PMH significant for HTN who developed
substernal chest pressure while working outside in his yard.  He
went inside and lay down on the floor in front of the fan where
he was found by his wife.  She called EMS and he denied fall or
LOC when they arrived.  He received aspirin, nitro, and NS and
was transfered to the [**Hospital3 3583**].  In [**Hospital1 46**], he was
hypertensive to 164/118 and bradycardic to 42.  His EKG was
significant for complete heart block with ST elevations in II,
III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2.
He was started on heparin, aggrastat, asa and morphine prior to
being transfered to [**Hospital1 18**].  Of note, his wife said that he has
developed mild pedal edema over the past few days and states
that his exercise tolerance has dropped recently.
.
In the cath lab, he was seen to be actuely vagal with
hypotension and emesis.  He was also acutely acidotic and
hypoxic.  He was intubated for airway protection.  An
intra-aortic balloon pump was placed secondary to his
hypotension.  He had several episodes of VT that aborted with
amiodarone 150mg bolus and lidocaine 75mg bolus.  He was started
on an amiodarone drip.  His cath demonstrated a totally occluded
mid-RCA that was stented.  His RPL was ballooned.  His right
sided filling pressures were elevated with a PCW 37, RA 27, RV
62/18, and PA 62/38.  He had no step up.  He received 80mg of
lasix in the lab.

Past Medical History:
HTN
asthma
lumbar disc herniation

Social History:
no smoking, social alcohol, no ivdu.  lives w/ wife and
daughter.

Family History:
father died at 49 from MI and  mother w/ cardiac issues "at
birth" and died at 49 from "cardiac issues". siblings w/out
medical issues

Physical Exam:
Gen: Pt intubated and sedated with an OG tube
HEENT: PERRL
Neck: -LAD
CV: RRR, s1/s2 intact, -M/G/R
Lungs: Coarse breath sounds b/l
Abd: S/NT/ND, + BS
Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B
Ext: -C/C/E, palpable LE pulses b/l


Pertinent Results:
[**2178-8-29**] 03:57PM BLOOD WBC-18.3* RBC-4.67 Hgb-14.6 Hct-41.6
MCV-89 MCH-31.4 MCHC-35.2* RDW-13.6 Plt Ct-223
[**2178-8-29**] 03:57PM BLOOD Neuts-85.3* Lymphs-10.9* Monos-3.4
Eos-0.2 Baso-0.1
[**2178-8-29**] 03:57PM BLOOD PT-16.4* PTT-150* INR(PT)-1.8
[**2178-8-29**] 03:57PM BLOOD Glucose-159* UreaN-18 Creat-1.4* Na-139
K-3.4 Cl-108 HCO3-15* AnGap-19
[**2178-8-29**] 11:30PM BLOOD CK(CPK)-3357*
[**2178-8-30**] 04:51AM BLOOD CK(CPK)-4161*
[**2178-8-30**] 11:49AM BLOOD CK(CPK)-4962*
[**2178-8-31**] 12:37AM BLOOD CK(CPK)-4473*
[**2178-8-31**] 04:43AM BLOOD CK(CPK)-3865*
[**2178-9-1**] 03:57AM BLOOD ALT-104* AST-169* LD(LDH)-975* AlkPhos-40
TotBili-1.8*
[**2178-8-29**] 11:30PM BLOOD CK-MB-GREATER TH
[**2178-8-30**] 04:51AM BLOOD CK-MB-GREATER TH
[**2178-8-30**] 11:49AM BLOOD CK-MB-420* MB Indx-8.5*
[**2178-8-31**] 12:37AM BLOOD CK-MB-235* MB Indx-5.3 cTropnT-10.06*
[**2178-8-31**] 04:43AM BLOOD CK-MB-149* MB Indx-3.9
[**2178-9-2**] 03:27AM BLOOD calTIBC-186* VitB12-210* Folate-11.4
Ferritn-451* TRF-143*
[**2178-8-30**] 04:51AM BLOOD Triglyc-80 HDL-43 CHOL/HD-3.2 LDLcalc-80
.
ECHO [**8-21**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with inferior and
inferio-lateral hypokinesis. The RV size and systolic function
are probably within normal limits (suboptimal views). The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Trivial mitral regurgitation
is seen. There is an anterior space which most likely represents
a fat pad.
.
Cath [**8-21**]:
1. Selective coronary angiography revealed a right dominant
system with
acute occlusion of a large right coronary artery before it gave
off any
marginal branches.  The LMCA had no significant disease.  The
LAD had
mild diffuse luminal plaquing up to 40% along its length.  The
LCx was
non-dominant and had no significant coronary artery disease.
After the
RCA thrombotic stenosis was treated, there was evidence of
distal
emoblization with an abrupt cut off of the terminal R PDA.
2. Hemodynamics revealed severely elevated left and right heart
filling
pressures.  The RV and PA pressures were elevated above 50mm Hg
systolic, suggesting some element of chronic pulmonary
hypertension.
The cardiac output and index were preserved however this was in
the face
of dopamine infusion which was probably causing some degree of
splanchnic vasodilation and L > R shunting.
3. Left ventriculography was not performed.
4. Successful placement of temporary 5 French pacing wire during

procedure for heart block via the right femoral vein without
complications. The pacing wire was removed at the conclusion of
the
procedure.
5. Successful placement of 8 French, 40 cc IABP via the left
femoral
artery under fluoroscopic guidance without complications.
Appropriate
systolic unloading and diastolic augmentation were noted with
invasive
hemodynamic measurements.
6. Intubation for hypoxemia, acidemia, and airway control during
the
procedure without complications and with fluoroscopic
confirmation of
appropriate ETT placement.
7. Successful treatment of culprit mid-RCA with a 3.5 x 18 mm
Cypher
drug-eluting stent postdilated with a 3.75 mm balloon. Final
angigraphy
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
8. Successful treatment of thrombus migration to the r-PL using
balloon
inflations with a 2.5 x 15 mm Voyager balloon. Final angiography

demonstrated no significant residual stenosis, no
angiographically
apparent dissection, and normal flow


Brief Hospital Course:
A/P: Pt is a 54 y/o man w/ a PMH significant for HTN who
presented to [**Hospital1 18**] for urgent cath in the setting of an acute
infero-posterior STEMI.
.
1. CAD - pt presented after an acute infero-posterior STEMI and
received an RCA stent.  he was intubated during this process for
respiratory compromise in the setting of cardiogenic shock
during his catheterization.  he was started on aspirin, statin,
bb, plavix, and ace in the post-catheterization setting.  he
received an echo showing an EF of 45% and
inferior/infero-lateral hypokinesis.  he developed a large
hematoma at the groin site that resolved throughout his stay.
he did not have cp after the intervention and tolerated PT
evaluation w/out complaint.  he was d/c home on his inpatient
medications w/ close follow-up.
.
2. Hypotension: the patient developed cardiogenic shock during
his catheterization requiring IABP and dopamine.  he received 9
L total between OSH and [**Hospital1 18**].  he was weaned off both the
pressors and iabp in the ccu in the days after his
catheterization w/out problem.  his bp was monitored w/ an
a-line until transfer to the floor.  he was started on bb and
ace after his pressors were weaned and his pressure had
normalized.  he tolerated both of these well and was d/c home to
continue bp titration as an outpatient.
.
3. Arrhythmia - pt w/ VT in the cath lab that spontaneously
aborted and was most likely secondary to ischemia and subsequent
reperfusion.  he was transiently placed on an amiodarone drip
overnight but was taken off this the next morning and did not
have recurrence of arrhythmia throughout his stay.
.
4. Respiratory - pt w/ a hx of asthma and was intubated for
airway protection during cath.  he bit through his ngt while in
the ccu and was noted to have aspirated.  empiric abx were
started and the pt subsequently developed a fever/wbc bump that
responded well to abx.  he was slowly weaned off his sedation
and extubated successfully following a spontaneous breathing
trial.  he was on supplemental oxygen after extubation but this
was slowly weaned both in the ccu and on the floor.
.
5. ARF - pt developed mild arf w/ Cr of 1.4 here (1.2 at outside
hospital).  his cr normalized throughout his stay and his ace-i
was started after his cr normalized.
.


Medications on Admission:
Univasc
primatene mist

Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-18**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Dicloxacillin Sodium 250 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Infero-lateral ST elevation MI

Discharge Condition:
Stable

Discharge Instructions:
Please keep all your appointments as scheduled
Please take all of your medications as directed
Do NOT stop your plavix or aspirin without taking to your
cardiologist first.
Return to the ER/Call your PCP [**Name Initial (PRE) **]:
1. chest pain
2. shortness of breath
3. fever to 101
4. fainting spells
5. other alarming symptoms

Followup Instructions:
Please see Dr. [**Last Name (STitle) 63700**] in [**Hospital Ward Name 23**] 7 on [**2178-10-5**] at 1:15pm
([**Telephone/Fax (1) 4022**])
Please see Dr [**Last Name (STitle) 32467**]



Completed by:[**2178-10-20**]
{'Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Conduction disorder, unspecified,Asthma, unspecified type, unspecified,Displacement of lumbar intervertebral disc without myelopathy'}


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: Pt is a 54 y/o man w/ a PMH significant for HTN who developed
substernal chest pressure while working outside in his yard.  He
went inside and lay down on the floor in front of the fan where
he was found by his wife.  She called EMS and he denied fall or
LOC when they arrived.  He received aspirin, nitro, and NS and
was transfered to the [**Hospital3 3583**].  In [**Hospital1 46**], he was
hypertensive to 164/118 and bradycardic to 42.  His EKG was
significant for complete heart block with ST elevations in II,
III, aVF, and V3-6 as well as ST depressions in I, aVL, V1-2.
He was started on heparin, aggrastat, asa and morphine prior to
being transfered to [**Hospital1 18**].  Of note, his wife said that he has
developed mild pedal edema over the past few days and states
that his exercise tolerance has dropped recently.
.
In the cath lab, he was seen to be actuely vagal with
hypotension and emesis.  He was also acutely acidotic and
hypoxic.  He was intubated for airway protection.  An
intra-aortic balloon pump was placed secondary to his
hypotension.  He had several episodes of VT that aborted with
amiodarone 150mg bolus and lidocaine 75mg bolus.  He was started
on an amiodarone drip.  His cath demonstrated a totally occluded
mid-RCA that was stented.  His RPL was ballooned.  His right
sided filling pressures were elevated with a PCW 37, RA 27, RV
62/18, and PA 62/38.  He had no step up.  He received 80mg of
lasix in the lab.

MEDICAL HISTORY: HTN
asthma
lumbar disc herniation

MEDICATION ON ADMISSION: Univasc
primatene mist

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Pt intubated and sedated with an OG tube
HEENT: PERRL
Neck: -LAD
CV: RRR, s1/s2 intact, -M/G/R
Lungs: Coarse breath sounds b/l
Abd: S/NT/ND, + BS
Groin: R groin oozing w/out hematoma/bruit, L groin w/out O/H/B
Ext: -C/C/E, palpable LE pulses b/l

FAMILY HISTORY: father died at 49 from MI and  mother w/ cardiac issues "at
birth" and died at 49 from "cardiac issues". siblings w/out
medical issues

SOCIAL HISTORY: no smoking, social alcohol, no ivdu.  lives w/ wife and
daughter. 

### Response:
{'Acute myocardial infarction of inferoposterior wall, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Hematoma complicating a procedure,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Conduction disorder, unspecified,Asthma, unspecified type, unspecified,Displacement of lumbar intervertebral disc without myelopathy'}
