CHIEF COMPLAINT: Chest heaviness

PRESENT ILLNESS: Patient is an 87 year old female with history of hypertension
who presents with chest heaviness. Patient was in her usual
state of health until the morning prior to admission, when she
experienced chest "heaviness" and "lumpiness", substernal,
radiating to left arm. She describes the sensation as
non-painful, and not very distressing, except that she had never
experienced it before and it was constant/persistent. The day of
admission, the heaviness began to intensify after lunch, around
2 pm. Patient lives at [**Location (un) **] independent living and became
concerned with the persistence of her symptoms, so she contact[**Name (NI) **]
the home nurses associated with [**Location (un) **]. Per her nurses, she
was denying pain at the time they evaluated her but she was
complaining of L arm tingling. Her vitals at the time: BP
160/100, HR 100s, satting 98% on RA. She appeared diaphoretic.
Her nurses contact[**Name (NI) **] EMS, who checked an EKG which demonstated
ST elevations in leads III and AVF. She was transferred to [**Hospital1 18**]
for further eval.
.
In the ED, initial vitals were: Pulse 112, SBP 167, rr 26, 99%
ra. An EKG demonstrated ST elevations in leads II (1mm), III and
aVF (2+mm), with reciprocal ST depressions in I, aVL, and V2.
Cath lab was activated. Pt received plavix 600 mg po x1,
morphine 1 mg, asa 325 mg po x1, and was placed on 4000 units of
heparin, plus heparin gtt. During cath, pt was noted to have 90%
stenosis of proximal LAD to diagonal, LCX with 80-90 % proximal
disease.

MEDICAL HISTORY: (no previous hospitalizations)
1) Hypertension
2) Multiple basal cell cancers and one SCC on leg, s/p surgery
3) s/p R eye cataract surgery

MEDICATION ON ADMISSION: Toprol 75 mg daily
Quinipril 20 mg daily
HCTZ 25 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.2 P 116 BP 137/76 R 23 SO2 98% on 3L nc
Gen - Alert, no acute distress
HEENT - Right pupil 4mm, Left 2 mm, c/w baseline s/p cataract
surgery, extraocular motions intact, anicteric, dry mucous
membranes
Neck - Supple, JVP 9 cm, no cervical lymphadenopathy, no thyroid
enlargement, no carotid bruits
Chest - Clear to auscultation bilaterally
CV - Tachycardia, regular rhythm, normal S1/S2, S3, no murmurs
or gallops.
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, no organomegaly
Extr - No clubbing, cyanosis, or edema. 2+ DP/PT pulses
bilaterally. Right groin with hard mass, approximately 8 cm in
diameter, centered around cath insertion site, non-tender,
cannot assess bruit. Minimal external bleeding from site.
Neuro - Alert and oriented x 3, cranial nerves [**2-16**] intact
Skin - No rash, good turgor

FAMILY HISTORY: Strokes in multiple members, brother MI at 74.

SOCIAL HISTORY: Patient lives at independent living with home nursing as above.
No tobacco history, drinks one EtOH per 2 months. Never married,
no children.
Acute myocardial infarction of other inferior wall, initial episode of care,Acute diastolic heart failure,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Anemia, unspecified,Other specified hypotension,Personal history of other malignant neoplasm of skin,Unspecified essential hypertension
AMI inferior wall, init,Ac diastolic hrt failure,Hematoma complic proc,Parox ventric tachycard,Crnry athrscl natve vssl,Abn react-cardiac cath,Accid in resident instit,Anemia NOS,Hypotension NEC,Hx-skin malignancy NEC,Hypertension NOS
Name:  [**Known lastname 12644**],[**Known firstname **]                   Unit No:   [**Numeric Identifier 12645**]

Admission Date:  [**2106-6-12**]              Discharge Date:   [**2106-6-16**]

Date of Birth:  [**2018-8-23**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4871**]
Addendum:
Clarification of secondary diagnosis:
Acute diastolic heart failure

Discharge Disposition:
Home With Service

Facility:
[**Location (un) 4641**] Home Health Care

                             [**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 4878**] MD [**MD Number(1) 4879**]

Completed by:[**2106-7-28**]

Admission Date:  [**2106-6-12**]              Discharge Date:   [**2106-6-16**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest heaviness

Major Surgical or Invasive Procedure:
Cardiac catherization with PTCA and placement of bare metal
stent in proximal RCA.


History of Present Illness:
Patient is an 87 year old female with history of hypertension
who presents with chest heaviness. Patient was in her usual
state of health until the morning prior to admission, when she
experienced chest "heaviness" and "lumpiness", substernal,
radiating to left arm. She describes the sensation as
non-painful, and not very distressing, except that she had never
experienced it before and it was constant/persistent. The day of
admission, the heaviness began to intensify after lunch, around
2 pm. Patient lives at [**Location (un) **] independent living and became
concerned with the persistence of her symptoms, so she contact[**Name (NI) **]
the home nurses associated with [**Location (un) **]. Per her nurses, she
was denying pain at the time they evaluated her but she was
complaining of L arm tingling. Her vitals at the time: BP
160/100, HR 100s, satting 98% on RA. She appeared diaphoretic.
Her nurses contact[**Name (NI) **] EMS, who checked an EKG which demonstated
ST elevations in leads III and AVF. She was transferred to [**Hospital1 18**]
for further eval.
.
In the ED, initial vitals were: Pulse 112, SBP 167, rr 26, 99%
ra. An EKG demonstrated ST elevations in leads II (1mm), III and
aVF (2+mm), with reciprocal ST depressions in I, aVL, and V2.
Cath lab was activated. Pt received plavix 600 mg po x1,
morphine 1 mg, asa 325 mg po x1, and was placed on 4000 units of
heparin, plus heparin gtt. During cath, pt was noted to have 90%
stenosis of proximal LAD to diagonal, LCX with 80-90 % proximal
disease.


Past Medical History:
(no previous hospitalizations)
1) Hypertension
2) Multiple basal cell cancers and one SCC on leg, s/p surgery
3) s/p R eye cataract surgery


Social History:
Patient lives at independent living with home nursing as above.
No tobacco history, drinks one EtOH per 2 months. Never married,
no children.

Family History:
Strokes in multiple members, brother MI at 74.


Physical Exam:
Vitals: T 98.2 P 116 BP 137/76 R 23 SO2 98% on 3L nc
Gen - Alert, no acute distress
HEENT - Right pupil 4mm, Left 2 mm, c/w baseline s/p cataract
surgery, extraocular motions intact, anicteric, dry mucous
membranes
Neck - Supple, JVP 9 cm, no cervical lymphadenopathy, no thyroid
enlargement, no carotid bruits
Chest - Clear to auscultation bilaterally
CV - Tachycardia, regular rhythm, normal S1/S2, S3, no murmurs
or gallops.
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, no organomegaly
Extr - No clubbing, cyanosis, or edema. 2+ DP/PT pulses
bilaterally. Right groin with hard mass, approximately 8 cm in
diameter, centered around cath insertion site, non-tender,
cannot assess bruit. Minimal external bleeding from site.
Neuro - Alert and oriented x 3, cranial nerves [**2-16**] intact
Skin - No rash, good turgor


Pertinent Results:
Na 142, K 3.8, Cl 104, HCO3 29, BUN 15, Cr 0.8, Glu 174
WBC 9.2, HGb 13.7, HCt 41.7, Plt 236, MCV 91
PT 12.4, PTT 24.9, INR 1.0
CK 249, MB 36, MB index 14.5, TropT 0.25
.
EKG: Sinus rhythm, rate 113. Normal QRS axis. Normal PR, QRS,
and QT intervals. [**Street Address(2) 4793**] elevation in II, [**Street Address(2) 1766**] elevations in
III and aVF. ST depressions of 1 mm in I, 2 mm in aVL, and 3 mm
in V2. No Q waves.
.
CATH: Right dominant system revealed 3 vessel CAD. The LMCA had
no apparent disease. The LAD had a 90% proximal stenosis to D1
and formed a twin system with a diagonal and large septal that
gave collaterals to the RCA. There was a large ramus with a
diffuse 80-90%
stenosis. The RCA had a 100% stenosis proximally. Resting
hemodynamics: RA mean pressure of 12 mm Hg. The RVSP was 62
with an RVEDP of 15 mm Hg. The PASP was 62 mm Hg with a mean of
45 mm
Hg. The PCWP was elevated at 35 mm Hg. The cardiac output was
5.0 and
index 2.9. LV gram deferred. Successful PCI/stent to proximal
RCA with a 2.5mm x 23mm Vision stent postdilated with a 3.0mm NC
balloon. Excellent result with normal flow down vessel and no
residual stenosis.
.
Transthoracic Echo [**2106-6-14**]:
Findings
LEFT ATRIUM: Normal LA size.

LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
No LV mass/thrombus. Overall normal LVEF (>55%). No resting LVOT
gradient. No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
valvular AS. The increased transaortic velocity is related to
high cardiac output. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Moderate PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. No masses or thrombi are seen in the left ventricle.
There is focal apical hypokinesis. The remaining segments are
hyperdynamic. Overall left ventricular systolic function is
preserved (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.


Brief Hospital Course:
Patient is an 87 year old woman with hypertension who presented
with an inferior STEMI.
.
# Coronary artery disease: Patient had several risk factors,
including HTN and hyperlipidemia but had no prior history of
myocardial infarction or anginal symptoms. Her EKG was
consistent with an inferior STEMI with 100% occluded RCA,
3-vessel disease found on catherization. She had a bare metal
stent placed in the RCA. She may require require further
intervention for disease noted in her left circumflex and LAD,
to be determined in several weeks time after outpatient follow
up. Her CK peaked at 1722 (MB 278) at 12 am on [**2106-6-13**]. She had
one additional episode ofchest pain on [**6-13**], with an EKG showed
TWI and <1 mm STE in V3-V6. No intervention was taken.
At time of discharge, she was on changed to simvastatin 80 mg
(from atorvastatin 80 mg), Plavix 75 mg, Aspirin 325 mg, and
12.5 mg of metoprolol twice daily. Of note, her baseline liver
function tests were mildly elevated, possibly in setting of
myocardial infarction. She was not able to tolerate addition of
an ace-inhibitor or further up-titration of her beta-blocker due
to asymptomatic hypotension overnight while sleeping (systolic
in the 80's).
- Further titration of her beta-blocker, including transition to
a once-daily formulation, and addition of an ace-inhibitor, may
be further managed on an outpatient basis in follow-up.
.
# Heart function: Patient has had no prior echo. She had no
difficulties with oxygenation or shortness of breath. Her JVP
was noted to be mildly elevated at 9 cm. Her left and right
heart catherizations revealed elevated pressures, suggestive of
left ventricular systolic dysfunction in setting of inferior
myocardial infarction versus diastolic dysfunction in setting of
longstanding hypertension. She may also have some right
ventricular involvement with RCA occlusion. She was mildly
diruesed until she appeared euvolemic.  A transthoracic echo was
completed on [**6-14**] which showed a cardiac output of 10 L/min, 1+
MR, 1+ TR, EF of 55%. She had no clinical signs of failure, a
normal TSH 3.7, stable (although trending downward HCT), and tiw
as felt that the high output was most likely inaccurate
calculation of CO on Echo.
.
# Rhythm: Patient remained in sinus rhythm while monitored on
telemetry without any arrythmias.
.
# Hypertension: Patient's home medications were held. She had
borderline low blood pressure, so further uptitration of her
metoprolol and additional of other agents was deferred until
outpatient follow up. She was instructed to NOT resume her home
blood pressure medications until follow up.
.
# Anemia: Patient's baseline hematocrit per her primary care
physician's office was 40.7 in 4/[**2106**]. During her stay, she had
a stable slow drift downward in her hematocrit from 38-40 down
to 30. She had no signs of bleeding and her stools were guaiac
negative. Further work-up and evaluation of her anemia should be
completed as appropriate on an outpatient basis.
.
# White count: Patient had a leukocytosis to 17,000, but no
clinical signs of infection. It was felt that this was likely
secondary to her myocardial infection, and trended downward
during her stay.
.
# Disposition: Patient stayed on the cardiology floor for an
additional day to monitor her hematocrit and blood pressure,
both of which were stable. She was discharged home after being
cleared by physical therapy, and will receive physical therapy
at home. Cardiac rehabilitation was recommended. A copy of her
discharge summary was faxed to her primary care physician's
office (Dr. [**Last Name (STitle) 35888**] at [**Location 1268**] VA, Fax # ([**Telephone/Fax (1) 78513**].
Office number is ([**Telephone/Fax (1) 78514**]). A follow-up appointment was in
place with Dr. [**Last Name (STitle) **] for approximately two weeks after
discharge, and she will see her primary care physician within [**Name Initial (PRE) **]
week of discharge.
.
# Code: Patient was full code during her admission.

Medications on Admission:
Toprol 75 mg daily
Quinipril 20 mg daily
HCTZ 25 mg daily


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
4. Lumigan 0.03 % Drops Sig: One (1)  Ophthalmic as prescribed:
Please take as formerly prescribed.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): Please take one tablet if
you have chest pain.  If the chest pain does not go away repeat
another tablet and call 911 and go to your nearest emergency
room.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Home Health Care

Discharge Diagnosis:
Primary diagnosis:
- Inferior myocardial infarction

Secondary diagnosis:
- Hypertension
- Multiple basal cell cancers and one SCC on leg, s/p surgery
- s/p R eye cataract surgery


Discharge Condition:
Stable


Discharge Instructions:
You were admitted due to a heart attack. You underwent cardiac
catherization and had a stent placed in a blocked artery. You
were monitored closely in the cardiac intensive care unit and
did well. A number of new medications were started. You will
need to continue these medications, especially your aspirin and
Plavix. Do not stop these unless instructed by your
cardiologist.  You were also started on a cholesterol medication
called simvastatin.
.
We made serveral changes to your medications:  Please
discontinue Quinapril and hydrochlorthiazide.   We also changed
toprol 75mg once a day to metoprolol 12.5 mg twice a day
.
Please speak with your cardiologist (at the follow up
appointment) re: cardiac rehabilitation.
.
Please contact your cardiologist, primary care physician, [**Name10 (NameIs) **] go
to the emergency room if you have chest pain, shortness of
breath or any concerning symptoms.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (cardiologist who performed
your catherization) at an appointment made for you on [**7-5**]
at 4:20 PM. His office is located on the [**Location (un) 436**] of the
[**Hospital Ward Name 23**] Building.
.
Please follow up with your primary care physician within the
next week, at the appointment previously made.
{'Acute myocardial infarction of other inferior wall, initial episode of care,Acute diastolic heart failure,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Anemia, unspecified,Other specified hypotension,Personal history of other malignant neoplasm of skin,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 heaviness

PRESENT ILLNESS: Patient is an 87 year old female with history of hypertension
who presents with chest heaviness. Patient was in her usual
state of health until the morning prior to admission, when she
experienced chest "heaviness" and "lumpiness", substernal,
radiating to left arm. She describes the sensation as
non-painful, and not very distressing, except that she had never
experienced it before and it was constant/persistent. The day of
admission, the heaviness began to intensify after lunch, around
2 pm. Patient lives at [**Location (un) **] independent living and became
concerned with the persistence of her symptoms, so she contact[**Name (NI) **]
the home nurses associated with [**Location (un) **]. Per her nurses, she
was denying pain at the time they evaluated her but she was
complaining of L arm tingling. Her vitals at the time: BP
160/100, HR 100s, satting 98% on RA. She appeared diaphoretic.
Her nurses contact[**Name (NI) **] EMS, who checked an EKG which demonstated
ST elevations in leads III and AVF. She was transferred to [**Hospital1 18**]
for further eval.
.
In the ED, initial vitals were: Pulse 112, SBP 167, rr 26, 99%
ra. An EKG demonstrated ST elevations in leads II (1mm), III and
aVF (2+mm), with reciprocal ST depressions in I, aVL, and V2.
Cath lab was activated. Pt received plavix 600 mg po x1,
morphine 1 mg, asa 325 mg po x1, and was placed on 4000 units of
heparin, plus heparin gtt. During cath, pt was noted to have 90%
stenosis of proximal LAD to diagonal, LCX with 80-90 % proximal
disease.

MEDICAL HISTORY: (no previous hospitalizations)
1) Hypertension
2) Multiple basal cell cancers and one SCC on leg, s/p surgery
3) s/p R eye cataract surgery

MEDICATION ON ADMISSION: Toprol 75 mg daily
Quinipril 20 mg daily
HCTZ 25 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.2 P 116 BP 137/76 R 23 SO2 98% on 3L nc
Gen - Alert, no acute distress
HEENT - Right pupil 4mm, Left 2 mm, c/w baseline s/p cataract
surgery, extraocular motions intact, anicteric, dry mucous
membranes
Neck - Supple, JVP 9 cm, no cervical lymphadenopathy, no thyroid
enlargement, no carotid bruits
Chest - Clear to auscultation bilaterally
CV - Tachycardia, regular rhythm, normal S1/S2, S3, no murmurs
or gallops.
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds, no organomegaly
Extr - No clubbing, cyanosis, or edema. 2+ DP/PT pulses
bilaterally. Right groin with hard mass, approximately 8 cm in
diameter, centered around cath insertion site, non-tender,
cannot assess bruit. Minimal external bleeding from site.
Neuro - Alert and oriented x 3, cranial nerves [**2-16**] intact
Skin - No rash, good turgor

FAMILY HISTORY: Strokes in multiple members, brother MI at 74.

SOCIAL HISTORY: Patient lives at independent living with home nursing as above.
No tobacco history, drinks one EtOH per 2 months. Never married,
no children. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Acute diastolic heart failure,Hematoma complicating a procedure,Paroxysmal ventricular tachycardia,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Anemia, unspecified,Other specified hypotension,Personal history of other malignant neoplasm of skin,Unspecified essential hypertension'}
