CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: HPI: 61 y/o F with h/o CAD s/p anteroseptal MI who presents s/p
?VFib arrest in CT scanner.  She presented to the ED with 10/10
chest pain with associated SOB and diaphoresis.  No EKG changes
and nl initial enzymes.  She received ASA, nitro, lopressor 5
IV/50 PO, anzemet, and MSO4.  CXR showed widened mediastinum.
In the CT scanner she became unresponsive after one bolus of
contrast.  CODE Blue was called and she was found to be in in
VFib; she converted after a 300 and 360 J shock to sinus
rhythym.  She was intubated and taken for cardiac cath.  She
underwent stenting of a 70% proximal RCA lesion.  RA pressure
16, CO 5, CI 2.5. She is admitted to the CCU service for further
management and continued to be hemodynamically stable.
.
ROS: Pt unable to provide; per ED note she reported multiple
episodes of blood-streaked emesis.  Decreased PO intake.  No abd
pain, bloody BMs, or diarrhea.  No F/C.  No SI/HI.

MEDICAL HISTORY: CAD s/p anteroseptal MI - 2 yrs ago
HTN
Gout
s/p L Nephrectomy - TB in kidney?
Depression s/p suicide attempts
Seizure disorder
h/o Opiod abuse
h/o ETOH abuse
Lumbar stenosis
h/o B12 deficiency
+ PPD - was tx for 1 year
.

MEDICATION ON ADMISSION: Medications: taken from d/c summary in [**2152**].
1. Senna 8.6 mg Tablet PO BID
2. Docusate Sodium 100 mg Capsule PO BID
3. Bisacodyl 5 mg Tablet PO DAILY prn
4. Zolpidem 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 99.5  P: 70  BP: 123/82  SaO2: 100% on CMV
600/12/1.00/5
General: intubated, sedated
HEENT: NC/AT.  pupils were pinpoint, sclera anicteric.  ETT tube
in place.
Neck: supple, thick.
Pulm: Lungs clear anteriorly
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Rectal: guaiac negative in ED
Ext: No edema b/t, 2+ radial, femoral, DP and PT pulses b/l.  R
groin TLC in place.
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: multiple excoriations, linear cut marks
Neurologic: sedated and intubated.

FAMILY HISTORY: no premature CAD

SOCIAL HISTORY: Smoking quit 20 yrs ago, lives by herself. hx of Alcohol and
drug of abuse.
Ventricular fibrillation,Other convulsions,Major depressive affective disorder, single episode, unspecified,Borderline personality disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Coronary atherosclerosis of native coronary artery,Gout, unspecified,Unspecified essential hypertension
Ventricular fibrillation,Convulsions NEC,Depress psychosis-unspec,Borderline personality,Spin sten,lumbr wo claud,Crnry athrscl natve vssl,Gout NOS,Hypertension NOS
Admission Date:  [**2154-7-29**]              Discharge Date:   [**2154-8-4**]

Date of Birth:  [**2093-6-8**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
cardiac catheterization
endotracheal intubation
PICC line placement


History of Present Illness:
HPI: 61 y/o F with h/o CAD s/p anteroseptal MI who presents s/p
?VFib arrest in CT scanner.  She presented to the ED with 10/10
chest pain with associated SOB and diaphoresis.  No EKG changes
and nl initial enzymes.  She received ASA, nitro, lopressor 5
IV/50 PO, anzemet, and MSO4.  CXR showed widened mediastinum.
In the CT scanner she became unresponsive after one bolus of
contrast.  CODE Blue was called and she was found to be in in
VFib; she converted after a 300 and 360 J shock to sinus
rhythym.  She was intubated and taken for cardiac cath.  She
underwent stenting of a 70% proximal RCA lesion.  RA pressure
16, CO 5, CI 2.5. She is admitted to the CCU service for further
management and continued to be hemodynamically stable.
.
ROS: Pt unable to provide; per ED note she reported multiple
episodes of blood-streaked emesis.  Decreased PO intake.  No abd
pain, bloody BMs, or diarrhea.  No F/C.  No SI/HI.


Past Medical History:
CAD s/p anteroseptal MI - 2 yrs ago
HTN
Gout
s/p L Nephrectomy - TB in kidney?
Depression s/p suicide attempts
Seizure disorder
h/o Opiod abuse
h/o ETOH abuse
Lumbar stenosis
h/o B12 deficiency
+ PPD - was tx for 1 year
.


Social History:
Smoking quit 20 yrs ago, lives by herself. hx of Alcohol and
drug of abuse.


Family History:
no premature CAD

Physical Exam:
Admission Physical Exam:
Vitals: T: 99.5  P: 70  BP: 123/82  SaO2: 100% on CMV
600/12/1.00/5
General: intubated, sedated
HEENT: NC/AT.  pupils were pinpoint, sclera anicteric.  ETT tube
in place.
Neck: supple, thick.
Pulm: Lungs clear anteriorly
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Rectal: guaiac negative in ED
Ext: No edema b/t, 2+ radial, femoral, DP and PT pulses b/l.  R
groin TLC in place.
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: multiple excoriations, linear cut marks
Neurologic: sedated and intubated.


Pertinent Results:
Admission Labs:
.
[**2154-7-29**] 05:25PM BLOOD WBC-7.1# RBC-3.91* Hgb-13.2 Hct-38.1
MCV-97 MCH-33.9* MCHC-34.8 RDW-20.6* Plt Ct-238
[**2154-7-29**] 05:25PM BLOOD Neuts-81.1* Lymphs-13.0* Monos-4.8
Eos-1.0 Baso-0.1
[**2154-7-29**] 05:25PM BLOOD Anisocy-2+ Macrocy-3+
[**2154-7-29**] 05:25PM BLOOD Plt Ct-238
[**2154-7-29**] 05:25PM BLOOD Glucose-101 UreaN-8 Creat-0.7 Na-134
K-8.1* Cl-98 HCO3-16* AnGap-28*
[**2154-7-29**] 05:25PM BLOOD CK(CPK)-84
[**2154-7-29**] 05:25PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2154-7-29**] 08:00PM BLOOD Calcium-8.3* Phos-3.5 Mg-1.7
[**2154-7-29**] 08:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
.
Other Labs:
[**2154-8-1**]  05:29AM Vit B 12 813; Folate 4.0; Ferritin 264*; TIBC
183*; Iron 106
.
EKG:
Initial EKG: ST @ 117, nl axis, nl intervals, <[**Street Address(2) 4793**] dep in
V3/V4
EKG #2: NSR @ 83 bpm, nl axis, QTc 472.  no ST changes.
.
Radiologic Data:
CXR [**2154-7-29**]: Endotracheal tube tip near right main stem
bronchus.  Recommend withdrawal by 4-5 cm.
.
CTA [**2154-7-29**]: No definite evidence of proximal pulmonary
embolism.  This exam is limited secondary to heart motion and
evaluation of the more peripheral branches of the pulmonary
arterial vasculature is not well assessed.
2.  No evidence of pneumonia.
3.  Coronary artery calcifications
.
Cath [**2154-7-29**]:
1) Selective coronary angiography of this right dominant system
revealed one vessel coronary artery disease.  The left main
coronary artery was without angiographic evidence of obstructive
coronary artery disease.
The left anterior descending coronary artery had mild
atherosclerotic
disease throughout.  The left circumflex coronary artery had
mild
atherosclerotic disease throughtout.  The right coronary artery
had a
70-80% proximal stenosis.  There were no lesions in the mid or
distal
RCA.
2) Resting hemodynamics revealed mildly elevated right and left
sided
filling pressures.  There was no evidence of pulmonary
hypertension.
The cardiac output and index were preserved at 5.0 and 2.5
respectively
3) Successful direct stenting of the proximal RCA was performed
with a 3.0x18 mm Cypher stent.  Final angiography revealed 0%
residual
stenosis, no dissection, and TIMI 3 flow.  (see PTCA comments)
CONCLUSIONS:
1. One vessel coronary artery disease.
2. Mildly elevated right and left sided filling pressures.
3. Successful stenting of the proximal RCA.
.
Echo ([**2154-7-30**]):
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal akinesis of the basal inferior wall. The
remaining  segments contract well/are hyperdynamic. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. Mild (1+) aortic regurgitation is suggested
(could not be confirmed). The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
.
Abdominal U/S [**2154-7-31**]:
1. No ascites or biliary dilatation identified.
2. Diffuse increased echogenicity of the liver consistent with
fatty infiltration. Other forms of liver disease and more
advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
.
Microbiology
[**2154-8-1**] H. Pylori Ab test negative
Urine Cx and Blood Cxs and sputum cx were negative during this
admission
.
Discharge Labs:
[**2154-8-4**] 05:14AM BLOOD Hct-30.2


Brief Hospital Course:
61 y/o F with h/o CAD s/p anteroseptal MI who presented with
chest pain and arrested in CT scanner, which required
intubation.  Her hospital course for this admission is as
follows:
.
1. Questionable V fib arrest - It was unclear whether patient
had VF when she became unresponsive at the CT scan, our leading
explaination was that she had a respiratory arrest after one
dose of IV contrast for chest CT, in setting of vomiting and low
bicarb, also some QT prolongation.  No recorded strip available
for confirmation.   She received two shocks at 300J and 360J,
which converted her back to sinus rhythm.  Her initial serum
drug screen was negative.  She was started on amiordorone gtt
for ? V fib, but developed prolonged QT, so amiodorone was
stopped, and QT inteval normalized.  Her urine tox screen was
positive for benzo and opioids, but she received versed and
fentanyl during cath.  Given she presented with chest pain and
she coded at the CT scan, she was taken to the cath lab which
showed one vessel disease (70% stenosis of RCA) and stent was
placed, and she was started on ASA and plavix post cath.  Given
her initial CK and tropinin was negative, it was unlikely that
ischemia is the course of her chest pain on presentation. Echo
showed LVEF >70% with normal LV thickness.  We monitored her on
telemetry, and she remained NSR without any events throughout
her hopsital stay.  We don't think there is any need for
defibrillator given normal EF.
.
2. Ischemia - patient presented with chest pain, N/V, SOB and
diaphoresis, although her initial CK and tropinin was negative,
and ECG showed no evidence of acute change suggesting ischemia.
However, she coded while at the CT scan, given her initial
presentation of chest pain, she was intubated and taken directly
to the cath lab which showed one vessel disease 70% stenosis of
RCA s/p Cypher stenting. Echo showed >70% EF with normal LV
thickness. Regional left ventricular systolic dysfunction c/w
CAD. She was started on ASA 325' and plavix 75', and started
metoprolol 12.5mg PO bid, which was increased to 37.5mg PO bid
at the time of discharge. She was initially started on imdur
60mg (home dose), but was discontinued on this admission given
tolerating increasing bblock doses.
.
3 HTN - initially hypertensive, hypotensive in ED on propofol.
We started metoprolol and titrated up as tolerated.
.
4 Resp - intubated during cardiac arrest; gradually wean vent
and self-extubation on [**2154-7-30**], gradually weaned her off the
supplemental O2.  She was saturating up 90% on RA at the time of
discharge.
.
5 Abd pain/nausea and vomiting - patient initially presented
with abdominal pain/N/V.  Intially chest CT showed fatty liver,
and RUQ ultradsound showed normal gall bladder and fatty liver.
Her abdominal/N/V resolved prior to discharge.
.
6 Anemia - She was anemic post-cath (Hct in the 23-24), iron
studies showed anemia of chronic disease, normal Folate and B12.
 Given concerns for GI bleeding, GI was consulted, but no EGD
per GI due to multiple cardiac risk factors at this time.  She
was transfused a total of 2 units of pRBCs on this admission,
her discharge Hct is 30.2.  She was told to follow up with her
PCP for outpatient anemia workup.
.
7 Psych - Patient has MDD and borderline personality disorder.
She states she has suicidal ideation but both her outpatient
psychiatrsit (Dr. [**Last Name (STitle) 36038**] and psych feels like this is just for
attention;  She was initially on 1:1 sitter, but d/c'ed per
psych rec.  She admits to significant EtOH history, we started
cymbalta 30 mg [**Hospital1 **] per psych rec and continued Oxcarbazepine 300
mg PO TID.  We started her on CIWA precautions Q8H, and
lorazepam 2 mg prn when CIWA >10.  She was to follow up with her
outpatient pscyhiatrist on [**8-6**].
.
8 Chronic pain - She was initially started on both PO and IV
pain meds, but we d/c'ed IV morphine and dilaudid, and only
continued home narcotic regimen.  She did well on this regimen.
.
9 Diet - cardiac healthy diet
.
10. Prophylaxis - PPI, SC heparin, bowel regimen
.
11 Code Status: Full presumed

Medications on Admission:
Medications: taken from d/c summary in [**2152**].
1. Senna 8.6 mg Tablet PO BID
2. Docusate Sodium 100 mg Capsule PO BID
3. Bisacodyl 5 mg Tablet PO DAILY prn
4. Zolpidem 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime).

5. Clonidine 0.1 mg Tablet PO DAILY
6. Colchicine 0.6 mg Tablet PO BID
7. Pantoprazole 40 mg Tablet, PO Q24H (every 24 hours).
8. Aspirin 81 mg Tablet, PO DAILY (Daily).
9. Atorvastatin 20 mg Tablet PO DAILY
10. Oxcarbazepine 300 mg Tablet PO BID
11. Duloxetine 20 mg Capsule PO BID (2 times a day).
12. Metoprolol Tartrate 25 mg PO BID
13. Amlodipine 5 mg Tablet PO DAILY (Daily).
14. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
15. Morphine 180 mg Tablet Sustained Release PO Q12H
16. Quinine Sulfate 325 mg PO HS
17. Morphine Sulfate 4-8 mg IV Q4H:PRN
18. Hydromorphone 8 mg Tablet PO QID

Allergies:  NKDA


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Morphine 30 mg Tablet Sustained Release Sig: Six (6) Tablet
Sustained Release PO QPM (once a day (in the evening)).
4. Morphine 30 mg Tablet Sustained Release Sig: Four (4) Tablet
Sustained Release PO QAM (once a day (in the morning)).
5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary diagnosis:
Chest pain
Major depression
Anemia
.
Secondary diagnosis:
HTN
Gout
s/p L Nephrectomy - TB in kidney?
Depression s/p suicide attempts
Seizure disorder
h/o Opiod abuse
h/o ETOH abuse
Lumbar stenosis
h/o B12 deficiency
chronic pain


Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.


Discharge Instructions:
If you experience any chest pain, SOB, heart palpitations,
fever, or abdominal pain different than your baseline or any
other serious medical condition, please go to the emergency room
immediately.
.
You have had a cardiac catherization with a stent placed in one
of your coronary arteries to keep it open.  You have been
started on ASA 325 mg and plavix 75 mg by mouth every day post
cath and stent placement.  Please make sure you take them
everyday to keep the stents open.  DO NOT MISS A SINGLE DOSE.
.
You are anemic in the hospital requiring two units of pRBC
transfusion.  Please follow up with your PCP for work up of
anemia (EGD and/or colonoscopy).
.
Please take your medications as prescribed.
.
Please follow up with your appointments see below.


Followup Instructions:
Please follow up with your psychiatrist Dr [**Last Name (STitle) 36038**] on [**2154-8-6**] at
10:00am.
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**12-17**] weeks by calling
([**Telephone/Fax (1) 99274**] for an appointment.
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiologist) in [**12-17**]
weeks ([**Telephone/Fax (1) 5909**] for an follow up appointment.



Completed by:[**2154-8-4**]
{'Ventricular fibrillation,Other convulsions,Major depressive affective disorder, single episode, unspecified,Borderline personality disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Coronary atherosclerosis of native coronary artery,Gout, unspecified,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: HPI: 61 y/o F with h/o CAD s/p anteroseptal MI who presents s/p
?VFib arrest in CT scanner.  She presented to the ED with 10/10
chest pain with associated SOB and diaphoresis.  No EKG changes
and nl initial enzymes.  She received ASA, nitro, lopressor 5
IV/50 PO, anzemet, and MSO4.  CXR showed widened mediastinum.
In the CT scanner she became unresponsive after one bolus of
contrast.  CODE Blue was called and she was found to be in in
VFib; she converted after a 300 and 360 J shock to sinus
rhythym.  She was intubated and taken for cardiac cath.  She
underwent stenting of a 70% proximal RCA lesion.  RA pressure
16, CO 5, CI 2.5. She is admitted to the CCU service for further
management and continued to be hemodynamically stable.
.
ROS: Pt unable to provide; per ED note she reported multiple
episodes of blood-streaked emesis.  Decreased PO intake.  No abd
pain, bloody BMs, or diarrhea.  No F/C.  No SI/HI.

MEDICAL HISTORY: CAD s/p anteroseptal MI - 2 yrs ago
HTN
Gout
s/p L Nephrectomy - TB in kidney?
Depression s/p suicide attempts
Seizure disorder
h/o Opiod abuse
h/o ETOH abuse
Lumbar stenosis
h/o B12 deficiency
+ PPD - was tx for 1 year
.

MEDICATION ON ADMISSION: Medications: taken from d/c summary in [**2152**].
1. Senna 8.6 mg Tablet PO BID
2. Docusate Sodium 100 mg Capsule PO BID
3. Bisacodyl 5 mg Tablet PO DAILY prn
4. Zolpidem 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 99.5  P: 70  BP: 123/82  SaO2: 100% on CMV
600/12/1.00/5
General: intubated, sedated
HEENT: NC/AT.  pupils were pinpoint, sclera anicteric.  ETT tube
in place.
Neck: supple, thick.
Pulm: Lungs clear anteriorly
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Rectal: guaiac negative in ED
Ext: No edema b/t, 2+ radial, femoral, DP and PT pulses b/l.  R
groin TLC in place.
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: multiple excoriations, linear cut marks
Neurologic: sedated and intubated.

FAMILY HISTORY: no premature CAD

SOCIAL HISTORY: Smoking quit 20 yrs ago, lives by herself. hx of Alcohol and
drug of abuse. 

### Response:
{'Ventricular fibrillation,Other convulsions,Major depressive affective disorder, single episode, unspecified,Borderline personality disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Coronary atherosclerosis of native coronary artery,Gout, unspecified,Unspecified essential hypertension'}
