CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: 83 yo female with a history of HTN, hyperlipidemia, diastolic
CHF, ESRD on HD, h/o CVA, and Alzheimers dementia presents from
dialysis with a wide complex tachycardia.  Patient denies any
chest pain, shortness of breath, or other complaints.  On the
day of admission, she presented for her routine dialysis
appointment. During the visit she was noted to look unwell and
not herself.  On arrival of EMS, BP 77/50, HR 121, RR 16, O2
95%.  Patient was brought to [**Hospital1 18**] ED for eval.
.
On arrival, HR 135, BP 90/60, RR 16 O2 90%.  On exam, irregular
rhythym, no JVD, guaiac negative.  ECG revealed a wide complex
tachycardia at rate of 140bpm.  Patient was given Amio and
Calcium gluconate.  Then spontaneously converted to NSR at [**Street Address(2) 14412**] elevations inferiorly in II, III, aVF (III > II)
also with reciprocal depression in I, aVL, V6, V5.  Labs with CK
379, MB 43, MBI 11.3, TnT 13.4.  The patient was given Aspirin,
heparin, intergrillin (couldn't swallow plavix) and taken to the
cath lab.
.
Left Heart Cardiac Catheterization demonstrated;
 1.  CTO of RCA
 2.  LMCA: Distal taper with moderate calcification
 3.  LAD: Proximal 50% w/ heavy calcification, D1 80% lesion.
 4.  LCx: Non-dominant w/ distal flow from l-r collaterals
 5.  Unable to cross CTO of RCA though unlikely acute.
.
Patient was then transferred to the CCU for management.
.
On review of symptoms, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools.  She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CRI secondary to HTN.
2. HTN
3. CVA of posterolateral medulla in [**2095**]. Pt previously on
coumadin, but recently held by PCP due to concern about falls.
4. Hypercholesterolemia
5. Polio at age 18 with residual left lower extremity weakness
6. Aortic insufficiency
7. TR/MR [**First Name (Titles) **] [**Last Name (Titles) **] 12'[**95**]
8. s/p bilateral cataracts surgery
9. s/p TAH secondary to uterine fibroids
10. CHF - Diastolic Dysfunction
11. cognitive impairment

MEDICATION ON ADMISSION: Pantoprazole 40 mg daily
Toprol XL 25 mg daily
Atorvastatin 5 mg daily
Aspirin 325 mg daily
Donepezil 5 mg qhs
BComplex-Vitamin C-Folic Acid 1mg PO daily
nephrocaps

ALLERGIES: Sulfonamides / Penicillins

PHYSICAL EXAM: VS: T 94.1, BP 148/89 , HR 73, RR 25 , O2 100 % on 4L NC
Gen: Elderly woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+
palpable DP on R, dopplerable PT.
Left: Carotid 2+ without bruit; Femoral 1+ without bruit;
Dopplerable on Right but extremely faint.
Neuro: AOx3, "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]" is president, US "not" at war and
"Red Sox" won world series.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient lives alone in the [**Location (un) **] of [**Location (un) 86**]. She is
completely independent in her ADL and IADLS - she cooks, cleans,
Acute myocardial infarction of other inferior wall, initial episode of care,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Paroxysmal ventricular tachycardia,Cyst and pseudocyst of pancreas,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Hyperpotassemia,Aortic valve disorders,Late effects of acute poliomyelitis,Other and unspecified hyperlipidemia
AMI inferior wall, init,End stage renal disease,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,Parox ventric tachycard,Pancreat cyst/pseudocyst,Alzheimer's disease,Dementia w/o behav dist,Crnry athrscl natve vssl,Hyperpotassemia,Aortic valve disorder,Late effect acute polio,Hyperlipidemia NEC/NOS
Admission Date:  [**2104-10-27**]              Discharge Date:   [**2104-11-3**]


Service: MEDICINE

Allergies:
Sulfonamides / Penicillins

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
Cardiac Catheterization


History of Present Illness:
83 yo female with a history of HTN, hyperlipidemia, diastolic
CHF, ESRD on HD, h/o CVA, and Alzheimers dementia presents from
dialysis with a wide complex tachycardia.  Patient denies any
chest pain, shortness of breath, or other complaints.  On the
day of admission, she presented for her routine dialysis
appointment. During the visit she was noted to look unwell and
not herself.  On arrival of EMS, BP 77/50, HR 121, RR 16, O2
95%.  Patient was brought to [**Hospital1 18**] ED for eval.
.
On arrival, HR 135, BP 90/60, RR 16 O2 90%.  On exam, irregular
rhythym, no JVD, guaiac negative.  ECG revealed a wide complex
tachycardia at rate of 140bpm.  Patient was given Amio and
Calcium gluconate.  Then spontaneously converted to NSR at [**Street Address(2) 14412**] elevations inferiorly in II, III, aVF (III > II)
also with reciprocal depression in I, aVL, V6, V5.  Labs with CK
379, MB 43, MBI 11.3, TnT 13.4.  The patient was given Aspirin,
heparin, intergrillin (couldn't swallow plavix) and taken to the
cath lab.
.
Left Heart Cardiac Catheterization demonstrated;
 1.  CTO of RCA
 2.  LMCA: Distal taper with moderate calcification
 3.  LAD: Proximal 50% w/ heavy calcification, D1 80% lesion.
 4.  LCx: Non-dominant w/ distal flow from l-r collaterals
 5.  Unable to cross CTO of RCA though unlikely acute.
.
Patient was then transferred to the CCU for management.
.
On review of symptoms, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools.  She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
1. CRI secondary to HTN.
2. HTN
3. CVA of posterolateral medulla in [**2095**]. Pt previously on
coumadin, but recently held by PCP due to concern about falls.
4. Hypercholesterolemia
5. Polio at age 18 with residual left lower extremity weakness
6. Aortic insufficiency
7. TR/MR [**First Name (Titles) **] [**Last Name (Titles) **] 12'[**95**]
8. s/p bilateral cataracts surgery
9. s/p TAH secondary to uterine fibroids
10. CHF - Diastolic Dysfunction
11. cognitive impairment


Social History:
The patient lives alone in the [**Location (un) **] of [**Location (un) 86**]. She is
completely independent in her ADL and IADLS - she cooks, cleans,

washes, dresses, herself. She is a retired nursing assistant.
She has no children and family is not involved, however pt has
friends who are involved in her life and care.Pt quit drinking
alcohol 50 years ago. Pt admits to smoking 0.3 pack/day for 3
years but also quit 50 years ago. Pt denies ever using illicit
drugs use.


Family History:
Noncontributory

Physical Exam:
VS: T 94.1, BP 148/89 , HR 73, RR 25 , O2 100 % on 4L NC
Gen: Elderly woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+
palpable DP on R, dopplerable PT.
Left: Carotid 2+ without bruit; Femoral 1+ without bruit;
Dopplerable on Right but extremely faint.
Neuro: AOx3, "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]" is president, US "not" at war and
"Red Sox" won world series.

Pertinent Results:
COMMENTS:
1.  Selective coronary angiography of this right dominant system

revealed 2 vessel coronary artery disease. The LMCA tapered
distally and
was noted to have moderate calcification.  The LAD had a
proximal 50%
stenosis with heavy calcification.  The D1 had an 80% stenosis
at the
origin.  The LCx was a non-dominant vessel without critical
lesions. The
RCA had a total occlusion with distal flow from left-to-right
collaterals.
2.  Resting hemodynamics revealed moderate-severe systemic
arterial
systolic hypertension with an SBP of 172 mmHg.
3.  Supravalvular aortography revealed no evidence of AI and a
normal
ascending aortic diameter.  The aortogram confirmed the total
occlusion
of the RCA.

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate to severe systemic arterial systolic hypertension.
3. Acute inferior myocardial infarction, managed by medical
therapy with
failed PTCA of complete total occlusion of RCA.

Cardiac Echo:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. There is mild regional left ventricular
systolic dysfunction with inferior hypokinesis. The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is mild functional mitral stenosis
(mean gradient 5 mmHg) due to mitral annular calcification.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.

[**2104-10-27**] 12:25PM   WBC-14.5*# RBC-3.21* HGB-9.8* HCT-31.2*
MCV-97 MCH-30.6 MCHC-31.5 RDW-16.8*
[**2104-10-27**] 12:25PM   CALCIUM-9.5 PHOSPHATE-6.4*# MAGNESIUM-2.3
[**2104-10-27**] 12:25PM   CK-MB-43* MB INDX-11.3* cTropnT-13.4*
[**2104-10-27**] 12:25PM   CK(CPK)-379*
[**2104-10-27**] 12:32PM   GLUCOSE-116* NA+-138 K+-5.7* CL--95* TCO2-23

Abdominal USD:
IMPRESSION:
1. No gallstones or intra- or extra-hepatic biliary ductal
dilatation.
2. Focal mild dilation of infrarenal aorta with nonocclusive
mural thrombus, not meeting size criteria for aneurysm.
3. Small kidneys consistent with end-stage renal disease.
4. Possible small cyst at the head of the pancreas; reevaluation
for stability is recommended in one year's time.

Brief Hospital Course:
Brief Hospital Course:
.
#CAD: Patient was admitted to the CCU post-cath for management.
Was continued on ASA 325mg, Plavix 75mg daily (with anticipated
duration of one month).  Metoprolol was started and titrated to
a dose of 37.5mg [**Hospital1 **].  Patient was started on captopril at low
dose (to be held pre-dialysis).  Additionally, lipitor 80mg qd
was initiated.  Patient was transfered to the floor post-cath
day 1 without event.  Echo demonstrated LV diastolic dysfunction
with preserved EF, RV dilated with depressed systolic function.
Echo demonstrated mild aortic stenosis.  Recommend outpatient
evaluation.
.
#V.Tach: Patient was monitored on telemetry in the CCU and later
on the floor.  During that time she had no significant runs of
NSVT and no recurrence of her VTach.  It was felt that her
initial presenting VT was likely due to the metabolic
derrangements (hyperkalemia) on presentation and decision was
made not to pursue an EP study at this time.
.
#ESRD: Patient was dialyzed on presentation.  Was mildly
hypotensive post-dialysis and BP meds were held. Patient was
then returned to her usual M/W/F dialysis regimen.  No further
events.
.
#Dementia/Social Work: Impression on admission was for mild
baseline dementia.  Attempts to discuss patient's care revealed
that she did not clearly have capacity.  After discussion with
the patient, social work, and administration it was decided that
patient's friend [**Name (NI) **] [**Name (NI) 3401**] ([**Telephone/Fax (1) 14413**] would serve as
healthcare proxy in the future.  Social work arranged
designation prior to discharge.
.
#Abd pain: patient complained of intermittent abdominal during
her hospitalization.  Abdominal exam was non-revealing with
intermittent RUQ tenderness. LFT's were normal for post-MI
setting and patient was followed clinically.  RUQ USD
demonstrated no significant biliary pathology.  A small cyst in
the head of the pancreas was noted which was recommended to be
reevaluated in 1-year's time.
.
#PT/OT: Rec'd--> discharge to rehab.
.
#Nutrition: Poor PO intake during her hospital stay thought to
be contributing to hypotension post-dialysis.  Nutrition
recommending renal diet, with encouraging PO intake when
possible.
.
#Follow-Up Plan: As per discharge plans.
.
Remainder of her hospitalization was uneventful.

Medications on Admission:
Pantoprazole 40 mg daily
Toprol XL 25 mg daily
Atorvastatin 5 mg daily
Aspirin 325 mg daily
Donepezil 5 mg qhs
BComplex-Vitamin C-Folic Acid 1mg PO daily
nephrocaps

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Epoetin Alfa  Injection
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Inc.

Discharge Diagnosis:
New diagnoses:
STEMI - inferior
Mild Aortic Stenosis (diagnosed by echo on recent admit)
.
End Stage Renal Disease, Dementia, Hypertension


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to the hospital for evaluation for low blood
pressure.  On arrival, it was found that you had an abnormal
heart rhythm and a previous heart attack.  You were taken to the
cardiac catheterization lab or an evaulation of the blood
vessels that supply your heart.  It was found that you have
coronary artery disease.  You were then admitted to the ICU for
observation and management.
.
Please continue to take all medications as directed upon leaving
the hospital.  The following medications have been added to your
medical regimen:
1.  Plavix 75mg daily - please continue to take for at least one
month.
2.  Lisinopril 2.5mg daily - please do not take on mornings of
dialysis.
3.  Atorvastatin 40mg daily
4.  Toprol 37.5mg [**Hospital1 **]
.
Please call your doctor or return to the emergency department
should you experience any sudden chest pain or shortness of
breath.


Followup Instructions:
Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 250**], please call for an appointment
in the next one month.
[**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**] Date/Time:[**2104-11-19**] 10:30
Dr. [**Last Name (STitle) **], Cardiology, [**Hospital Ward Name 23**] Building of [**Hospital3 **] [**Hospital Ward Name 5074**], [**Location (un) 436**], ([**Telephone/Fax (1) 11176**], Tuesday [**11-11**] at 1:40pm.
.
Repeat evaluation of pancreatic cyst in one-year's time for
interval change.
{"Acute myocardial infarction of other inferior wall, initial episode of care,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Paroxysmal ventricular tachycardia,Cyst and pseudocyst of pancreas,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Hyperpotassemia,Aortic valve disorders,Late effects of acute poliomyelitis,Other and unspecified hyperlipidemia"}


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: STEMI

PRESENT ILLNESS: 83 yo female with a history of HTN, hyperlipidemia, diastolic
CHF, ESRD on HD, h/o CVA, and Alzheimers dementia presents from
dialysis with a wide complex tachycardia.  Patient denies any
chest pain, shortness of breath, or other complaints.  On the
day of admission, she presented for her routine dialysis
appointment. During the visit she was noted to look unwell and
not herself.  On arrival of EMS, BP 77/50, HR 121, RR 16, O2
95%.  Patient was brought to [**Hospital1 18**] ED for eval.
.
On arrival, HR 135, BP 90/60, RR 16 O2 90%.  On exam, irregular
rhythym, no JVD, guaiac negative.  ECG revealed a wide complex
tachycardia at rate of 140bpm.  Patient was given Amio and
Calcium gluconate.  Then spontaneously converted to NSR at [**Street Address(2) 14412**] elevations inferiorly in II, III, aVF (III > II)
also with reciprocal depression in I, aVL, V6, V5.  Labs with CK
379, MB 43, MBI 11.3, TnT 13.4.  The patient was given Aspirin,
heparin, intergrillin (couldn't swallow plavix) and taken to the
cath lab.
.
Left Heart Cardiac Catheterization demonstrated;
 1.  CTO of RCA
 2.  LMCA: Distal taper with moderate calcification
 3.  LAD: Proximal 50% w/ heavy calcification, D1 80% lesion.
 4.  LCx: Non-dominant w/ distal flow from l-r collaterals
 5.  Unable to cross CTO of RCA though unlikely acute.
.
Patient was then transferred to the CCU for management.
.
On review of symptoms, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools.  She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CRI secondary to HTN.
2. HTN
3. CVA of posterolateral medulla in [**2095**]. Pt previously on
coumadin, but recently held by PCP due to concern about falls.
4. Hypercholesterolemia
5. Polio at age 18 with residual left lower extremity weakness
6. Aortic insufficiency
7. TR/MR [**First Name (Titles) **] [**Last Name (Titles) **] 12'[**95**]
8. s/p bilateral cataracts surgery
9. s/p TAH secondary to uterine fibroids
10. CHF - Diastolic Dysfunction
11. cognitive impairment

MEDICATION ON ADMISSION: Pantoprazole 40 mg daily
Toprol XL 25 mg daily
Atorvastatin 5 mg daily
Aspirin 325 mg daily
Donepezil 5 mg qhs
BComplex-Vitamin C-Folic Acid 1mg PO daily
nephrocaps

ALLERGIES: Sulfonamides / Penicillins

PHYSICAL EXAM: VS: T 94.1, BP 148/89 , HR 73, RR 25 , O2 100 % on 4L NC
Gen: Elderly woman in NAD, resp or otherwise. Oriented x3. Mood,
affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 1+ without bruit; 1+
palpable DP on R, dopplerable PT.
Left: Carotid 2+ without bruit; Femoral 1+ without bruit;
Dopplerable on Right but extremely faint.
Neuro: AOx3, "[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]" is president, US "not" at war and
"Red Sox" won world series.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient lives alone in the [**Location (un) **] of [**Location (un) 86**]. She is
completely independent in her ADL and IADLS - she cooks, cleans, 

### Response:
{"Acute myocardial infarction of other inferior wall, initial episode of care,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Paroxysmal ventricular tachycardia,Cyst and pseudocyst of pancreas,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Coronary atherosclerosis of native coronary artery,Hyperpotassemia,Aortic valve disorders,Late effects of acute poliomyelitis,Other and unspecified hyperlipidemia"}
