CHIEF COMPLAINT: Chest Pain, Dyspnea

PRESENT ILLNESS: Ms. [**Known lastname 174**] is a 63 year-old female with a history of CAD s/p CABG
(LIMA-LAD, SVG-Diag, SVG-RPL) and PCI with stent to LAD and LCX
[**2152**], systolic CHF (EF 25-30%), s/p ICD, post-operative PEs on
coumadin who had 6-8 weeks of worsening SOB with minimal
exertion and associated chest discomfort, [**1-12**] pillow orthopnea,
and PND.  SOB was not improved with home O2.  She was directly
admitted to [**Hospital1 18**] yesterday for heparin bridge for known PEs
prior to elective, repeat cardiac catheterization. However, on
admission, she described worsened SOB this AM with acute onset
of new [**5-19**] substernal chest pressure radiating to her left
neck/shoulder on arrival to the floor which was different than
her recent chest pain symptoms. Her pain was unresponsive to SL
NTG, and her paced EKG showed ST changes concerning for acute
ischemia (ST depressions in II, III, AVF and STE in AVL), so she
was given aspirin, loaded with plavix, started on a nitro gtt,
and transferred to the cath lab for urgent catheterization.
Cardiac enzymes at that time were negative.
.
In the cath lab her coronaries were found to be stable. LVEDP
was 43 so she was given lasix 40mg with 500 cc UOP.  PA gram to
look for PE was unrevealing.  Pt was transfered to the CCU
post-catheterization with stable vital signs.  She reported
improvement in her shortness of breath.  She continued to
complain of abdominal pain radiating to the chest, but her nitro
gtt was titrated off as her pain was non-cardiac.  She remained
stable overnight and was called out to the floor.
.
On the floor, the patient continues to complain of severe
abdominal pain which she describes as excruciating "torquing"
left upper quadrant pain radiating from under her left rib to
her chest and across her precordium.  She had difficulty
describing the quality, onset, and pattern of pain.  However,
she did report that she first experienced the pain in [**Month (only) 1096**]
as a "ripping" "tearing" pain at the site of her previous hernia
repair.  From her outside hospital records, she had presented to
Lakes [**Hospital 12018**] Hospital in the past for workup of her abdominal
pain.  She underwent a CT abdomen which, per records, showed a
small recurrance of her ventral hernia but no incarceration or
strangulation.  The surgeon decided not to re-operate on the
hernia.  The patient reports the pain is intermittently present
to fluctuating degrees of severity, but she reports she is never
pain-free.  Her pain is reportedly the worst it has been, and
the patient repeatedly is demanding Demerol for pain, which she
reports is the only medication which effectively relieves her
pain.  She also presented with a typed note, allegedly from the
PCP, [**Name10 (NameIs) 71539**] that Demerol is the only medication she may take
for pain.  The PCP was called, and reported he did not write the
note and that this would invalidate the patient's narcotic
contract.  Of note, she has had a history of narcotic abuse in
the past.
.
She denied any prior history of stroke, TIA, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denied recent fevers, chills or rigors. She
denied exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: (per pt's home med list)
- Carvedilol 6.25 mg po bid
- Amlodipine 10 mg po daily
- Furosemide 50 mg po bid
- Zolpidem 10 mg po qhs prn insomnia
- Oxycodone 15 mg po 2 per day (q3h prn pain)
- Percocet 10 mg po 2 per day (q4h prn pain)
* [**Name (NI) **] 325 mg po daily
- Pravastatin 40 mg po qhs
Potassium Chloride 20 mEq po tid  (10meq po daily)
- Warfarin 4 mg po qTuThSatSun, 2 mg qMWF
- Flovent Diskus 100mcg inhaled [**Hospital1 **]
- Senna 8.6 mg Capsule; 2 capsules po bid
- Docusate Sodium 100 mg po bid
(Lactulose 15ml [**Hospital1 **] prn)
(Bupropion XL 50 mg po tid (pt self-discontinued several weeks
ago as it made her "hyper"))
(Lexapro 10mg daily)
2L Oxygen

ALLERGIES: Compazine / Hydromorphone Hcl / Morphine / Lisinopril / Ace
Inhibitors / Trazodone / Nsaids

PHYSICAL EXAM: VS: T= 97.3 BP= 143/86 HR= 89 RR= 24 O2 sat= 98% on 3LNC.
GENERAL: 63 y/o F, uncomfortable, in NAD. Alert and oriented.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa. No xanthalesma noted.
NECK: Supple with no significant JVD noted.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

FAMILY HISTORY: Mother with valvular surgery; father died of PE. Reports history
of heart disease on mother's side (unable to give more details).

SOCIAL HISTORY: -Tobacco history: Quit 30 years ago; smoked 1 ppd x 15 years
-ETOH: Denies
-Illicit drugs: Denies
Of note, patient has a recent history of narcotic abuse and
manipulative drug-seeking behavior.
Acute on chronic combined systolic and diastolic heart failure,Other chest pain,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Abdominal pain, generalized,Other chronic pain
Ac/chr syst/dia hrt fail,Chest pain NEC,Crnry athrscl natve vssl,Aortocoronary bypass,Hyperlipidemia NEC/NOS,Hypertension NOS,Chr pulmon heart dis NEC,Abdmnal pain generalized,Chronic pain NEC
Admission Date:  [**2157-2-15**]              Discharge Date:   [**2157-2-17**]

Date of Birth:  [**2093-8-19**]             Sex:   F

Service: MEDICINE

Allergies:
Compazine / Hydromorphone Hcl / Morphine / Lisinopril / Ace
Inhibitors / Trazodone / Nsaids

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest Pain, Dyspnea

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
Ms. [**Known lastname 174**] is a 63 year-old female with a history of CAD s/p CABG
(LIMA-LAD, SVG-Diag, SVG-RPL) and PCI with stent to LAD and LCX
[**2152**], systolic CHF (EF 25-30%), s/p ICD, post-operative PEs on
coumadin who had 6-8 weeks of worsening SOB with minimal
exertion and associated chest discomfort, [**1-12**] pillow orthopnea,
and PND.  SOB was not improved with home O2.  She was directly
admitted to [**Hospital1 18**] yesterday for heparin bridge for known PEs
prior to elective, repeat cardiac catheterization. However, on
admission, she described worsened SOB this AM with acute onset
of new [**5-19**] substernal chest pressure radiating to her left
neck/shoulder on arrival to the floor which was different than
her recent chest pain symptoms. Her pain was unresponsive to SL
NTG, and her paced EKG showed ST changes concerning for acute
ischemia (ST depressions in II, III, AVF and STE in AVL), so she
was given aspirin, loaded with plavix, started on a nitro gtt,
and transferred to the cath lab for urgent catheterization.
Cardiac enzymes at that time were negative.
.
In the cath lab her coronaries were found to be stable. LVEDP
was 43 so she was given lasix 40mg with 500 cc UOP.  PA gram to
look for PE was unrevealing.  Pt was transfered to the CCU
post-catheterization with stable vital signs.  She reported
improvement in her shortness of breath.  She continued to
complain of abdominal pain radiating to the chest, but her nitro
gtt was titrated off as her pain was non-cardiac.  She remained
stable overnight and was called out to the floor.
.
On the floor, the patient continues to complain of severe
abdominal pain which she describes as excruciating "torquing"
left upper quadrant pain radiating from under her left rib to
her chest and across her precordium.  She had difficulty
describing the quality, onset, and pattern of pain.  However,
she did report that she first experienced the pain in [**Month (only) 1096**]
as a "ripping" "tearing" pain at the site of her previous hernia
repair.  From her outside hospital records, she had presented to
Lakes [**Hospital 12018**] Hospital in the past for workup of her abdominal
pain.  She underwent a CT abdomen which, per records, showed a
small recurrance of her ventral hernia but no incarceration or
strangulation.  The surgeon decided not to re-operate on the
hernia.  The patient reports the pain is intermittently present
to fluctuating degrees of severity, but she reports she is never
pain-free.  Her pain is reportedly the worst it has been, and
the patient repeatedly is demanding Demerol for pain, which she
reports is the only medication which effectively relieves her
pain.  She also presented with a typed note, allegedly from the
PCP, [**Name10 (NameIs) 71539**] that Demerol is the only medication she may take
for pain.  The PCP was called, and reported he did not write the
note and that this would invalidate the patient's narcotic
contract.  Of note, she has had a history of narcotic abuse in
the past.
.
She denied any prior history of stroke, TIA, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denied recent fevers, chills or rigors. She
denied exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY: MI x 2
-CABG:
s/p CABG [**12-16**] (LIMA to LAD, SVG to PLB, SVG to diag)
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**3-15**] LAD stenting at [**Hospital3 17921**] Center hospital
[**8-15**]: Cx stenting
-PACING/ICD:
s/p ICD
3. OTHER PAST MEDICAL HISTORY:
CAD as above
CABG complicated by a sternal wound infection
Systolic heart failure (LVEF 25-30%)
Hypertension (poorly controlled)
Depression
[**2153**]: Attempt at a ventral hernia repair, complicated by
development of a mesh infection requiring excision
Tonsillectomy
Appendectomy
Cholecystectomy
Hysterectomy
Chronic headaches
History of MVA complicated by "cerebral hematoma" and coma x 5
weeks
Prior colon surgery for a perforation
MRSA
Two prior ectopic pregnancies
Hx of multiple post surgical pulmonary emboli [**6-17**], on coumadin.

Social History:
-Tobacco history: Quit 30 years ago; smoked 1 ppd x 15 years
-ETOH: Denies
-Illicit drugs: Denies
Of note, patient has a recent history of narcotic abuse and
manipulative drug-seeking behavior.

Family History:
Mother with valvular surgery; father died of PE. Reports history
of heart disease on mother's side (unable to give more details).


Physical Exam:
VS: T= 97.3 BP= 143/86 HR= 89 RR= 24 O2 sat= 98% on 3LNC.
GENERAL: 63 y/o F, uncomfortable, in NAD. Alert and oriented.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa. No xanthalesma noted.
NECK: Supple with no significant JVD noted.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

LUNGS: Respirations were unlabored, no accessory muscle use.
CTAB, no crackles, wheezes or rhonchi noted anteriorly.
ABDOMEN: Obese, Soft, ND. Some tenderness in the upper abdomen,
greastest on the L side. No masses or HSM noted. No rebound or
guarding. BS present.
EXTREMITIES: WWP. Slight pitting edema at the ankles.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
appreciated.
NEURO: No gross neurologic deficits noted.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+


Pertinent Results:
Admission Labs
[**2157-2-15**] 04:16PM BLOOD WBC-6.9 RBC-4.03* Hgb-11.9* Hct-35.6*
MCV-88 MCH-29.4 MCHC-33.4 RDW-15.6* Plt Ct-263
[**2157-2-15**] 04:16PM BLOOD PT-19.3* PTT-26.2 INR(PT)-1.8*
[**2157-2-15**] 04:16PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-140
K-3.6 Cl-104 HCO3-25 AnGap-15
[**2157-2-15**] 04:16PM BLOOD Calcium-9.2 Phos-3.0# Mg-2.0
[**2157-2-15**] 06:04PM BLOOD Type-ART pO2-125* pCO2-34* pH-7.49*
calTCO2-27 Base XS-3 Intubat-NOT INTUBA
.
Cardiac Enzymes
[**2157-2-15**] 04:16PM CK(CPK)-193 CK-MB-7 cTropnT-<0.01
[**2157-2-16**] 05:27AM CK(CPK)-117 CK-MB-5 cTropnT-0.01
proBNP-3530*
.
.
Cardiac Catheterization ([**2157-2-15**]):
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated three
vessel CAD. The LMCA was patent with a 40% stenosis. The LAD was
a small
vessel with diffuse disease up to 40%. The LCx was occluded
proximally.
The RCA was diffusely diseased but patent with a 30% stenosis in
the mid
vessel.
2. Arterial conduit angiography revealed the LIMA to be small
but widely
patent. The SVG-Diag which also supplied OM1 was patent as was
the
SVG-PDA.
3. Resting hemodynamics revealed severely elevated right and
left sided
filling pressures with an RVEDP of 23 mmHg and an LVEDP of 43
mmHg.
There was severe pulmonary arterial systolic pressure with a
PASP of 67
mMHg. The cardiac index was preserved at 2.2 L/min/m2. There was

moderate systemic arterial systolic hypertension with an SBP of
144
mmHg.
4. There was no pressure gradient between the left ventricle and

ascending aorta on left heart pullback.
5. Left sided pulmonary angiography performed due to decreased
breath
sounds in the left lung fields did not demonstrate any discrete
filling defects to suggest a large pulmonary embolus.
.
FINAL DIAGNOSIS:
1. Three vessel CAD.
2. Severe left and right ventricular diastolic dysfunction.
3. Severe pulmonary hypertension
.
.
TTE ([**2157-2-16**]):
The left atrial volume is severely increased. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 20-25%).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.

Compared with the prior study (images reviewed) of [**2154-11-21**],
LV diastolic dimension has increased. The other findings are
similar. Cardiac dyssynchrony was not evaluated on the current
study.

Brief Hospital Course:
63 year-old female with PMHx of CAD s/p CABG and stents, sCHF,
PE on coumadin, HTN, HL with recently worsening dyspnea, who
developed intractable chest pain and underwent emergent
catheterization which showed stable CAD.
.
# CORONARIES: The patient was admitted for chest pain and for a
scheduled catheterization for further evaluation of her recent
dyspnea. However, she developed intractable chest pain while on
the floor and was noted to have ST depressions in II, III, aVF,
with STE in I, aVL. She underwent emergent cardiac
catheterization, which showed stable CAD. She was admitted to
the CCU for post-catheterization monitoring. CE's were negative
and she was transferred to the general cardiology floor for
management of bridging to Coumadin on Heparin gtt.  The patient
was transitioned to Lovenox on the day of discharge, to be taken
until her INR is therapeutic.  INR check will be performed by
[**Year (4 digits) 269**] two days following discharge and followed-up by her
cardiologist.  The patient was continued on her home aspirin,
beta blocker, statin, and continued to have chest/abdominal pain
(see below).
.
# PUMP: Pt with known sCHF with EF 23% in [**2153**], but with OSH TTE
from [**12/2156**] which showed mild-moderate MR with improved EF
25-30% compared to prior. Cardiac catheterization showed LVEDP
of 43, indicating volume overload. IV lasix was given for
diuresis. The patient's sCHF may be contributing to her dyspnea,
and she was discharged on her home Lasix with close f/u with her
cardiologist.
.
# RHYTHM: V-paced rhythm.  Patient was monitored on telemetry.
.
# Epigastric pain: Patient has a h/o of hernia repair with
recurrence of small hernia without strangulation which was
evaluated by her surgeon, who did not feel the need to
re-operate.  Patient has had a workup of her chronic abdominal
pain at OSHs, including CT abdomen and renal ultrasound per
PCP's office, which were unrevealing.  The patient was vague and
unwilling to describe or discuss her pain, and demanded IV
Demerol for pain relief.  Her exam revealed pain out of
proportion to exam and the pt was able to eat her meals without
pain.  Of note, she has a history of narcotic abuse and
drug-seeking behavior.  She presented to the hospital with a
note, allegedly from her PCP, [**Name10 (NameIs) 71539**] only Demerol 50mg IV
effectively treats her pain.  The PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was
contact[**Name (NI) **] and denied writing any such note.  As there is no
clear etiology for her pain, we conservatively managed her pain
with Tylenol, Tizanadine, and Darvocet prn.
.
# Dyspnea: The patient has a known history of sCHF (EF 23% in
[**2153**]), with elevated LVEDP on cardiac catheterization.  The
patient was diuresed post-cath with IV lasix in the cath lab and
in the CCU.  On the general cardiology floor, she subsequently
was dyspneic only with agitation, she was continued on her home
Lasix.  Pulmonary angiogram was negative for PE.  Additionally,
the patient's worsening dyspnea could represent worsening
underlying lung disease.  She was continued on her home Flovent.
.
# Hypertension: Pt with a history of uncontrolled hypertension,
but was adequately controlled in-house on home medications.
Continued carvedilol, amlodipine, lasix per outpatient regimen.
.
# H/o PE on Coumadin:  Pulmonary angiogram during
catheterization negative for PE.  Patient was bridged on Heparin
pre- and post-catheterization, and transitioned to Lovenox on
day of discharge.  Patient was discharged on home dose of
Coumadin with INR 1.7, and [**Year (4 digits) 269**] will draw INR on Saturday to
determine course of Lovenox.  Patient will also have f/u with
PCP on [**Name9 (PRE) 766**] for another INR check.
.
# Depression:  Patient self-discontinued buproprion and lexapro.
 Will need outpatient f/u.  SW was consulted in-house.  Prior to
discharge, the patient reported she would like to re-start her
Bupriprion and would be following up with her PCP the day after
discharge to discuss re-initiation of the medication.  She
requested one 50mg dose prior to discharge from the hospital and
was given a dose with instructions to follow-up with her PCP to
[**Name9 (PRE) 71540**] the medication and discuss the dosing (as she was
previously on a higher dose than she was willing to take).
.
CODE: FULL, confirmed with patient. HCP is friend [**Name (NI) **]
[**Name (NI) 71541**]

Medications on Admission:
(per pt's home med list)
- Carvedilol 6.25 mg po bid
- Amlodipine 10 mg po daily
- Furosemide 50 mg po bid
- Zolpidem 10 mg po qhs prn insomnia
- Oxycodone 15 mg po 2 per day (q3h prn pain)
- Percocet 10 mg po 2 per day (q4h prn pain)
* [**Name (NI) **] 325 mg po daily
- Pravastatin 40 mg po qhs
Potassium Chloride 20 mEq po tid  (10meq po daily)
- Warfarin 4 mg po qTuThSatSun, 2 mg qMWF
- Flovent Diskus 100mcg inhaled [**Hospital1 **]
- Senna 8.6 mg Capsule; 2 capsules po bid
- Docusate Sodium 100 mg po bid
(Lactulose 15ml [**Hospital1 **] prn)
(Bupropion XL 50 mg po tid (pt self-discontinued several weeks
ago as it made her "hyper"))
(Lexapro 10mg daily)
2L Oxygen

Discharge Medications:
1. Lovenox 100 mg/mL Syringe Sig: One (1)  Subcutaneous twice a
day for 7 days: Please take until directed by your physician to
stop (when INR is therapeutic).
Disp:*14 syringes* Refills:*0*
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Furosemide 20 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
5. Zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO once a day.
9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO qTuThSatSun.
10. Coumadin 2 mg Tablet Sig: One (1) Tablet PO qMonWedFri.
11. Flovent Diskus 100 mcg/Actuation Disk with Device Sig: One
(1)  Inhalation twice a day.
12. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Outpatient Lab Work
Please draw an INR on Saturday, [**2157-2-18**], and call Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 59323**] at [**Telephone/Fax (1) 71542**] with the results.


Discharge Disposition:
Home With Service

Facility:
[**First Name5 (NamePattern1) 6930**] [**Last Name (NamePattern1) **] Nurse Assoc and Hospice

Discharge Diagnosis:
Chest pain, non-cardiac
Chronic abdominal pain

Secondary Diagnosis:
Chronic Systolic Congestive Heart Failure
Ischemic cardiomyopathy


Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent


Discharge Instructions:
You presented to the hospital with stomach and chest pain, and
underwent a cardiac catheterization which showed stable coronary
artery disease which did not require any interventions.  There
were also no blood clots seen in your lungs.

You continued to have your chronic abdominal pain during your
hospital stay, but this was improved on the day of discharge.
You had been worked up for this in the past, and should follow
up with your primary care physician and [**Name Initial (PRE) **] surgeon regarding the
pain.  Please discuss all pain medications with your primary
care physician.

The following medication changes were made:
- Lovenox was added, to be taken until your physician tells you
to discontinue the medication (once your INR is therapeutic)

Please discuss all of your home medications with your primary
care physician, [**Name10 (NameIs) 71543**] your Buproprion (Wellbutrin).

Because you have heart failure, you should weigh yourself every
morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.

Followup Instructions:
Please call your Primary Care Physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 71544**], when you are discharged to arange for an
appointment on Monday [**2-21**] for a blood test to check your INR.
You should also arrange for a follow-up visit at that time, to
be seen by Dr. [**First Name (STitle) **] within 1-2 weeks after discharge from the
hospital.

Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59323**] at [**Telephone/Fax (1) 11254**] to arrnage for
a follow-up appointment within 1 week of your discharge from the
hospital.
{'Acute on chronic combined systolic and diastolic heart failure,Other chest pain,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Abdominal pain, generalized,Other chronic pain'}


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, Dyspnea

PRESENT ILLNESS: Ms. [**Known lastname 174**] is a 63 year-old female with a history of CAD s/p CABG
(LIMA-LAD, SVG-Diag, SVG-RPL) and PCI with stent to LAD and LCX
[**2152**], systolic CHF (EF 25-30%), s/p ICD, post-operative PEs on
coumadin who had 6-8 weeks of worsening SOB with minimal
exertion and associated chest discomfort, [**1-12**] pillow orthopnea,
and PND.  SOB was not improved with home O2.  She was directly
admitted to [**Hospital1 18**] yesterday for heparin bridge for known PEs
prior to elective, repeat cardiac catheterization. However, on
admission, she described worsened SOB this AM with acute onset
of new [**5-19**] substernal chest pressure radiating to her left
neck/shoulder on arrival to the floor which was different than
her recent chest pain symptoms. Her pain was unresponsive to SL
NTG, and her paced EKG showed ST changes concerning for acute
ischemia (ST depressions in II, III, AVF and STE in AVL), so she
was given aspirin, loaded with plavix, started on a nitro gtt,
and transferred to the cath lab for urgent catheterization.
Cardiac enzymes at that time were negative.
.
In the cath lab her coronaries were found to be stable. LVEDP
was 43 so she was given lasix 40mg with 500 cc UOP.  PA gram to
look for PE was unrevealing.  Pt was transfered to the CCU
post-catheterization with stable vital signs.  She reported
improvement in her shortness of breath.  She continued to
complain of abdominal pain radiating to the chest, but her nitro
gtt was titrated off as her pain was non-cardiac.  She remained
stable overnight and was called out to the floor.
.
On the floor, the patient continues to complain of severe
abdominal pain which she describes as excruciating "torquing"
left upper quadrant pain radiating from under her left rib to
her chest and across her precordium.  She had difficulty
describing the quality, onset, and pattern of pain.  However,
she did report that she first experienced the pain in [**Month (only) 1096**]
as a "ripping" "tearing" pain at the site of her previous hernia
repair.  From her outside hospital records, she had presented to
Lakes [**Hospital 12018**] Hospital in the past for workup of her abdominal
pain.  She underwent a CT abdomen which, per records, showed a
small recurrance of her ventral hernia but no incarceration or
strangulation.  The surgeon decided not to re-operate on the
hernia.  The patient reports the pain is intermittently present
to fluctuating degrees of severity, but she reports she is never
pain-free.  Her pain is reportedly the worst it has been, and
the patient repeatedly is demanding Demerol for pain, which she
reports is the only medication which effectively relieves her
pain.  She also presented with a typed note, allegedly from the
PCP, [**Name10 (NameIs) 71539**] that Demerol is the only medication she may take
for pain.  The PCP was called, and reported he did not write the
note and that this would invalidate the patient's narcotic
contract.  Of note, she has had a history of narcotic abuse in
the past.
.
She denied any prior history of stroke, TIA, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denied recent fevers, chills or rigors. She
denied exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: (per pt's home med list)
- Carvedilol 6.25 mg po bid
- Amlodipine 10 mg po daily
- Furosemide 50 mg po bid
- Zolpidem 10 mg po qhs prn insomnia
- Oxycodone 15 mg po 2 per day (q3h prn pain)
- Percocet 10 mg po 2 per day (q4h prn pain)
* [**Name (NI) **] 325 mg po daily
- Pravastatin 40 mg po qhs
Potassium Chloride 20 mEq po tid  (10meq po daily)
- Warfarin 4 mg po qTuThSatSun, 2 mg qMWF
- Flovent Diskus 100mcg inhaled [**Hospital1 **]
- Senna 8.6 mg Capsule; 2 capsules po bid
- Docusate Sodium 100 mg po bid
(Lactulose 15ml [**Hospital1 **] prn)
(Bupropion XL 50 mg po tid (pt self-discontinued several weeks
ago as it made her "hyper"))
(Lexapro 10mg daily)
2L Oxygen

ALLERGIES: Compazine / Hydromorphone Hcl / Morphine / Lisinopril / Ace
Inhibitors / Trazodone / Nsaids

PHYSICAL EXAM: VS: T= 97.3 BP= 143/86 HR= 89 RR= 24 O2 sat= 98% on 3LNC.
GENERAL: 63 y/o F, uncomfortable, in NAD. Alert and oriented.
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. No pallor or
cyanosis of the oral mucosa. No xanthalesma noted.
NECK: Supple with no significant JVD noted.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4 appreciated.

FAMILY HISTORY: Mother with valvular surgery; father died of PE. Reports history
of heart disease on mother's side (unable to give more details).

SOCIAL HISTORY: -Tobacco history: Quit 30 years ago; smoked 1 ppd x 15 years
-ETOH: Denies
-Illicit drugs: Denies
Of note, patient has a recent history of narcotic abuse and
manipulative drug-seeking behavior. 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Other chest pain,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Abdominal pain, generalized,Other chronic pain'}
