CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension
and coronary artery disease who presented with angina, now being
transferred to the CCU after bieng found to have left main
coronary artery disease.

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

MEDICATION ON ADMISSION: Norvasc 10mg daily
flomax
quinapril 20mg daily
Aspirin 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Afebrile, 127/55, 56, 12, 95% on room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and
left faintly reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at
LUSB
LUNGS: Anteriorly clear.
ABDOMEN: Soft, NTND.
EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses
BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches;
skin intact.
SKIN: No rashes.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

FAMILY HISTORY: (+) HTN, (+) CAD.

SOCIAL HISTORY: Orginially from [**Country 2784**]. Retured from teaching mechanical
engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no
drugs. Married.
Intermediate coronary syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Thrombocytopenia, unspecified,Spinal stenosis, unspecified region,Other specified cardiac dysrhythmias,Other specified anemias,Other diseases of lung, not elsewhere classified,Other left bundle branch block,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of urinary calculi,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Intermed coronary synd,Crbl art ocl NOS w infrc,Iatrogen CV infarc/hmrhg,Ac on chr diast hrt fail,Crnry athrscl natve vssl,Hypertension NOS,Thrombocytopenia NOS,Spinal stenosis NOS,Cardiac dysrhythmias NEC,Anemia NEC,Other lung disease NEC,Left bb block NEC,BPH w/o urinary obs/LUTS,Prsnl hst urnr dsrd calc,Abn react-cardiac cath
Admission Date:  [**2160-11-13**]              Discharge Date:   [**2160-11-18**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization


History of Present Illness:
Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension
and coronary artery disease who presented with angina, now being
transferred to the CCU after bieng found to have left main
coronary artery disease.

Six months prior to admission, began experiencing
"palpatations", described as chest pressure over the left
nipple. It would occur in the morning and occasionally
throughout the day and would be worsened by his morning weight
lifting. Each episode would last ~5-10 minutes. They were not
associated with SOB, diapheresis or nausea. He contact[**Name (NI) **] his PCP
he referred him to a cardiologist (Dr. [**Last Name (STitle) **]. A stress MIBI was
performed and reportedly positive per the patient though we do
not have the report. He was then prescribed SL nitro which he
took twice daily, with or without symptoms though he does
believe that taking it with symptoms did help.

Four months ago he underwent cataract surgery, at which time he
stopped aspirin. The surgery was uneventful.

Three months prio to admission, the angina resolved and he ran
out of nitro. Two weeks prior to admission he stopped aspirin in
preparation for spinal stenosis surgery. Five days prior to
admission, he again began to experience palpatations. He was in
[**State 108**] for his surgery and, upon describing his symptoms to the
anesthiologist, was cancelled. He flew back to [**Location (un) 86**] on [**11-13**]
and called his PCP who referred him to the ED for further
evaluation.

In the ED VSS, EKG showed old LBBB per his PCP. [**Name10 (NameIs) **] CP resolved
with SL NTG x1. He was given ASA 325mg and started on a heparin
gtt.

Overnight, he was continued on nitro and heparin gtts and had
stuttering chest pain. On the morning of transfer he was loaded
with Plavix 600mg and sent for cardiac cath where he was found
to have a 80% ulcerated left main lesion.

ROS
(-) PND/orthopnea
(+) Edema, chronic
(-) Fevers/chills/weight change
(+) Sinus congestion with Flomax
(-) Cough
(+) Occasional heart burn
(+) Constipation (BM every 2-3 days)
(-) Nausea/vomiting/diarrhea
(-) Bloody stools
(+) "Black stools"
(+) Chronic leg pain, anteriorly, though secondary to spinal
stenosis
Negative colonoscopy in [**2155**], per patient
PSA normal, per patient

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

2. CARDIAC HISTORY:
-CABG: None.
-PCI: None.
-PACING/ICD: None.

3. OTHER PAST MEDICAL HISTORY:
- Old LBBB (old per PCP)
- History of paroxysmal atrial fibrillation (patient denies)
- BPH
- Spinal Stenosis
- Cataracts, s/p surgery
- History of nephrolithiasis
- History of bilateral hip fracture, s/p repair (right in [**10-3**];
left in [**12-4**])

Social History:
Orginially from [**Country 2784**]. Retured from teaching mechanical
engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no
drugs. Married.


Family History:
(+) HTN, (+) CAD.

Physical Exam:
VS: Afebrile, 127/55, 56, 12, 95% on room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and
left faintly reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at
LUSB
LUNGS: Anteriorly clear.
ABDOMEN: Soft, NTND.
EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses
BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches;
skin intact.
SKIN: No rashes.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

Pertinent Results:
Laboratory values:
[**2160-11-13**] 06:05PM BLOOD WBC-6.2 RBC-4.64 Hgb-13.8* Hct-39.2*
MCV-85 MCH-29.9 MCHC-35.3* RDW-14.2 Plt Ct-142*
[**2160-11-16**] 04:09AM BLOOD WBC-6.3 RBC-4.13* Hgb-12.5* Hct-35.4*
MCV-86 MCH-30.4 MCHC-35.4* RDW-14.2 Plt Ct-144*

[**2160-11-13**] 06:05PM BLOOD PT-13.0 PTT-30.5 INR(PT)-1.1
[**2160-11-16**] 07:59AM BLOOD PT-12.8 PTT-50.3* INR(PT)-1.1

[**2160-11-16**] 07:59AM BLOOD FDP-0-10
[**2160-11-16**] 07:59AM BLOOD Fibrino-344 D-Dimer-As of [**10-28**]

[**2160-11-15**] 11:12AM BLOOD ESR-10

[**2160-11-13**] 06:05PM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-107 HCO3-26 AnGap-11
[**2160-11-16**] 04:09AM BLOOD Glucose-119* UreaN-19 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11

[**2160-11-14**] 04:00PM BLOOD ALT-11 AST-15 CK(CPK)-51 AlkPhos-60
Amylase-38 TotBili-0.9

[**2160-11-13**] 06:05PM BLOOD CK(CPK)-71
[**2160-11-14**] 02:39AM BLOOD CK(CPK)-57
[**2160-11-14**] 10:33AM BLOOD CK(CPK)-50
[**2160-11-13**] 06:05PM BLOOD cTropnT-0.02*
[**2160-11-14**] 02:39AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-11-14**] 10:33AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-11-14**] 04:00PM BLOOD cTropnT-0.03*

[**2160-11-15**] 02:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9

[**2160-11-16**] 07:59AM BLOOD D-Dimer-476

[**2160-11-14**] 04:00PM BLOOD VitB12-277

[**2160-11-15**] 11:12AM BLOOD Triglyc-44 HDL-60 CHOL/HD-3.0 LDLcalc-109
[**2160-11-15**] 11:12AM BLOOD CRP-15.3*

[**2160-11-14**] 10:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050*
[**2160-11-14**] 10:11PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG

Imaging/Studies:

CXR - 1.2 cm nodular opacity in the left upper lung zone,
concerning
for lung mass. Followup imaging is recommended.

ECG - Sinus rhythm with a first degree A-V block. Old left
bundle-branch block.

ECHO - The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%), mostly secondary
to left bundle branch block-related septal motion. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are three aortic valve
leaflets. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.

IMPRESSION: Symmetric LVH with borderline global systolic
function. Mild mitral regurgitation. Mild pulmonary
hypertension.

CT head w/o - IMPRESSION: Loss of [**Doctor Last Name 352**]-white matter
differentiation in the medial right frontal lobe, MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is recommended to rule out acute
infarction.

MRI/A head:
IMPRESSION:
1. Acute right anterior cerebral artery territorial infarct.
2. Tiny small areas of slow diffusion in the right parietal,
right medial
occipital, left parietal and the left frontal regions indicate
multiple small infarcts, which could be embolic in nature.

MRA OF THE HEAD:
Head MRA demonstrates normal flow signal within the arteries of
anterior and posterior circulation.

IMPRESSION: Normal MRA of the head.

Brief Hospital Course:
85M presenting with chest pain admitted initially to cardiology
service.  Patient continued to have chest pain and underwent
emergent catheterization and found to have left main disease. He
was transferred to the CCU to await CABG, but had a R ACA stroke
and CBAG was deferred. He was discharged to rehab in stable
condition.

# Coronary Artery Disease: Initially presented with concern for
unstable angina; ruled out by cardiac enzymes; ECG was difficult
to interpret in setting of LBBB. Medically managed overnight
with heparin gtt, nitro gtt, ASA, BB, statin. Caridac cath on
[**11-14**] showed LMCA ulcerated lesion of 70% and tortuous aorta.
Given LMCA lesion and its nature, patient was transferred to CCU
for further observation prior to possible CABG. He was continued
on ASA, heparin gtt and metoprolol and high dose statin. Nitro
gtt was started to maintain patient symptom free and maintain BP
<120. ASA was decreased to 81 mg QD. Patient was also started on
Integrillin drip on [**11-15**] which was discontinued on [**11-16**], given
no further catheterization. Metoprolol was started low dose, and
he is charged on 25mg toprol daily. ACEI held for now. Can start
amlodipine 5mg if neeeded at rehab.

# CVA: On [**11-15**] patient was noted to have LLE paresis and LUE
weakness, urinary incontinence on routine vitals check. VS were
stable. Given that these findings were new, neurology
consultation was immediately obtained. Last normal exam was 3
hrs prior to observation of symptoms. Heparin was temporarily
stopped given concern for intracranial hemorrhage (ICH). CT head
confirmed no ICH and heparin gtt was restarted. Given unclear
timing of the event, tPA was not administered. MRI of head
showed acute infarct in the Right ACA territory consistent w/
exam. Given relatively small size of infarction and being
outside of 5hr window, pt did not undergo MERCI retrieval. By
[**11-16**], patient's exam markedly improved w/ [**3-1**] distal and 4+/5
proximal LLE. At time of discharge pt's exam was [**3-1**] upper and
lower extremity strength. Per Neurology recommendations patient
was  started on coumadin for total duration of at least 3mo.
Patient discharged on Lovenox as bridge to therapeutic INR on
coumadin. Patient discharged to rehab and has neurology follow
up in 3 months.
.
# Acute on Chronic Diastolic Heart Failure: On admission,
patient had 2+ lower extremity edema dn elevated JVP to 10cm, no
prior history of heart failure. Echo showed symmetric LVH with
borderline global systolic function, EF 50-55%, likely secondary
to LBBB. Mild mitral regurgitation and mild pulmonary
hypertension were also noted. Given CVA, no lasix was
admininistered to maintain pressures > 120 systolic. ACE-I was
also held due to concern for hypotension, and betablocker dose
dose was decreased temporarily while hypotetnsive, but was
titrated back up to 12.5 mg [**Hospital1 **]. Patient was provided with [**Male First Name (un) **]
stockings.
.
# Sinus bradycardia: Bradycarid to the 50's throughout
admission. Patient has reported history of PAF but patient
denies this. Patient remained in sinus rhythm throughout
hospitalization. Given history of Atrial fibrillation, patient
will require 2wk monitoring of HR to assess for duration of
anticoagulation. If goes into atrial fibrillation, will likely
need life-long anticoagulation, to be determined by out patient
cardiologist.
.
# Acute Anemia: Patient was found to have Hct decreased from 39
to 34 post cath.  No active sources of bleeding were identified,
however pt had one guiac positive stool on [**11-17**]. HCT improved
to 35 by [**11-16**] and remained stable for the remainder of
hospitalization.
.
# Spinal Stenosis:  Surgery was delayed until cardiac disease
issues were resolved.  Patient was treated w/
oxycodone/acetaminphen and IV morphine prn for pain control.
.
# Hypertension: Patient was hypertensive on admission. He was
continued on home regimen of norvasc, quinopril and motoprolol
prior to catheterization w/ SBPs in 140-150 range. ACE-I and CBB
were held in setting of relative hypotension. amlodipine can be
restarted as needed.
.
# Lung Nodule: Noted on CXR as incidental finding, no priors for
comparison.
Patient will require CT as outpatient for further evaluation.
.
# Right Buttock Prior Decub Ulcer Site: Patient reports this is
site of prior decub which occured during hip fracture surgery.
Per his report, was difficult to heal.  On exam, a well healed,
erythematous area was noted.  Skin care w/ frequent
repositioning and dry dressings was performed.
.
# Propylaxis: DVT - lovenox 90mg sq [**Hospital1 **] transitioned to
warfarin.  Continue lovenox until therapeurtic INR ([**12-30**]) for 2
days. Protonix 40mg PO daily while in ICU, discontinued on
discharge.
.
# Code: FULL CODE

Medications on Admission:
Norvasc 10mg daily
flomax
quinapril 20mg daily
Aspirin 81mg daily

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose adjust for goal INR [**12-30**].  x 3 months (until [**2160-2-9**]).
8. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours): 90 mg sq [**Hospital1 **].  Continue until therapeutic
on coumadin (INR [**12-30**]) for 2 days.
9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary Diagnoses:
Unstable Angina
Left Main Coronary Artery Disease
Right Anterior Cerebral Artery Stroke

Secondary Diagnoses:
Left Bundle Branch Block
Hypertension
Spinal Stenosis
Possible history of Atrial Fibrillation
BPH


Discharge Condition:
Good, vitals stable.


Discharge Instructions:
You were admitted with chest pain and you had a cardiac
catheterization which showed a blockage the main left artery of
the heart which cannot be fixed with a stent. The cardiac
surgeons saw you and determined that you would be a candidate
for bypass surgery. Unfortunately, you had a small stroke as a
complication of the catheterization. Because of this, you will
need to go to rehab to regain your strength before considering
heart surgery.

Several medications were adjusted:
- Atorvastatin 80mg daily should be taken every day
- Toprol 25mg daily
- You were started on Coumadin for your stroke, this is a blood
thinner that prevents clots from forming. Lovenox will be
administered until the coumadin levels are therapeutic
- Quinipril has been held.

If you have chest pain, shortness of breath, high fever, pain at
your groin, severe abdominal pain, dizziness or lightheadedness
or any other concerning symptom, please seek medical care
immediately.

It was a pleasure meeting you and participating in your care.

Followup Instructions:
CARDIOLOGY:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2160-12-5**] at 10:30AM

NEUROLOGY:
Dr. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2574**] [**2161-2-17**] at 2:00pm

CARDIAC SURGERY:
Dr. [**Last Name (STitle) 81943**] [**Name (STitle) **] ([**Telephone/Fax (1) 6876**] on [**12-18**] (thursday) at
1:30 [**Initials (NamePattern4) **] [**Hospital Unit Name **], [**Location (un) **], suite A at [**Hospital1 18**] on the
[**Hospital Ward Name **].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Intermediate coronary syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Thrombocytopenia, unspecified,Spinal stenosis, unspecified region,Other specified cardiac dysrhythmias,Other specified anemias,Other diseases of lung, not elsewhere classified,Other left bundle branch block,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of urinary calculi,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Mr. [**Known lastname 22656**] is an 85 year-old man with a history of hypertension
and coronary artery disease who presented with angina, now being
transferred to the CCU after bieng found to have left main
coronary artery disease.

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

MEDICATION ON ADMISSION: Norvasc 10mg daily
flomax
quinapril 20mg daily
Aspirin 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Afebrile, 127/55, 56, 12, 95% on room air
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: MMM. NCAT. Sclera anicteric. Right pupil 3mm --> 2mm and
left faintly reactive, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: Regular rate, normal S1, S2. II/VI systolic murmur at
LUSB
LUNGS: Anteriorly clear.
ABDOMEN: Soft, NTND.
EXTREMITIES: 2+ edema bilaterally; 2+ DP pulses
BUTTOCK: 4x3cm tan discolorated area on right buttock; blanches;
skin intact.
SKIN: No rashes.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+

FAMILY HISTORY: (+) HTN, (+) CAD.

SOCIAL HISTORY: Orginially from [**Country 2784**]. Retured from teaching mechanical
engineering at [**University/College **]. Quit smoking 45 years ago, rare EtOH, no
drugs. Married. 

### Response:
{'Intermediate coronary syndrome,Cerebral artery occlusion, unspecified with cerebral infarction,Iatrogenic cerebrovascular infarction or hemorrhage,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Thrombocytopenia, unspecified,Spinal stenosis, unspecified region,Other specified cardiac dysrhythmias,Other specified anemias,Other diseases of lung, not elsewhere classified,Other left bundle branch block,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of urinary calculi,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
