CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: HPI: 74 yo man with PMH significant for CAD s/p MI and PTCA [**34**]
years ago and HTN presented to ED c/o vague epigastric
discomfort since 1 pm on [**7-13**], which gradually spread across
chest and was [**10-25**] sharp in quality.  Patient called 911.  In
ED, was able to be made pain-free with SLNTG.  Afterwards, SBP
dropped to 80s, but initial EKG without ischemic changes and 1st
set CEs negative.  While in ED, developed sudden onset of sharp
L-sided CP, different from presenting abdominal pain.  Patient
was diaphoretic and SBP down to 70s.  New EKG showed STE
anteriorly --> given fluid boluses and aspirin, plavix,
morphine, heparin gtt, integrillin gtt and brought to cath lab.
Temporary Wenkebach noted (no rhythm strips available).  In cath
lab, given 1 mg Atropine with improvement in BP and HR but
converted to A fib per cath report.  Cath revealed 2VD with mLAD
80% s/p 2 cypher stents and dLCx 80-90% s/p PTCA.  RHC showed RA
10, RV 45/10, PCWP 22, CO 4.5, CI 2.3 L/min/m2 and LVEF 45-50%.
Angioseal placed.  Patient denied CP, SOB after cath.
.
ROS negative for DOE, orthopnea, PND or LE edema.

MEDICAL HISTORY: PMH:
- HTN
- CAD s/p MI with PTCA ? to PDA in [**2117**]
- GERD (hiatal hernia x 35 years)
- MVP
- PVCs, ectopy
- seminoma s/p L orchiectomy

MEDICATION ON ADMISSION: Aspirin 75 mg po qd
Norvasc 5 mg po qd
Zantac prn

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T 97.7  BP 116/52 HR 84 15 100% on 2L NC
Drips: integrillin
GEN - NAD, A&Ox3
HEENT - PERRL, EOMI, OP clear
NECK - JVD 10 cm, supple, no LAD
HEART - regularly irregular, normal rate, no mrg
LUNGS - CTAB anterlaterally
ABD - soft, NT/ND, NABS
EXT - no edema
.

FAMILY HISTORY: - Father CAD s/p MI and death age 76
- Mom - colon CA age 81
- Sister - CAD
- Brother - HTN

SOCIAL HISTORY: - lives in [**Location 49506**], here in [**Location (un) 86**] visiting son.  Originally
from South [**Country 480**].  Denies tobacco use, occ EtOH.
- walks 3 km 3x/week
Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Hyposmolality and/or hyponatremia,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia, unspecified,Disorders of phosphorus metabolism,Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract,Unspecified essential hypertension,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease,Family history of malignant neoplasm of gastrointestinal tract,Esophageal reflux,Acquired absence of organ, genital organs
AMI anterior wall, init,Crnry athrscl natve vssl,Hyposmolality,Surg compl-heart,Cardiac dysrhythmias NEC,Iatrogenc hypotnsion NEC,Abn react-cardiac cath,Anemia NOS,Dis phosphorus metabol,Nonsp abn find-gi tract,Hypertension NOS,Old myocardial infarct,Status-post ptca,Fam hx-ischem heart dis,Family hx-gi malignancy,Esophageal reflux,Acq absnce genital organ
Admission Date:  [**2128-7-14**]              Discharge Date:   [**2128-7-16**]

Date of Birth:  [**2054-5-10**]             Sex:   M

Service: MEDICINE

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
Cardiac Catheterization s/p 2 stents placed to mid LAD and PTCA
to LCx


History of Present Illness:
HPI: 74 yo man with PMH significant for CAD s/p MI and PTCA [**34**]
years ago and HTN presented to ED c/o vague epigastric
discomfort since 1 pm on [**7-13**], which gradually spread across
chest and was [**10-25**] sharp in quality.  Patient called 911.  In
ED, was able to be made pain-free with SLNTG.  Afterwards, SBP
dropped to 80s, but initial EKG without ischemic changes and 1st
set CEs negative.  While in ED, developed sudden onset of sharp
L-sided CP, different from presenting abdominal pain.  Patient
was diaphoretic and SBP down to 70s.  New EKG showed STE
anteriorly --> given fluid boluses and aspirin, plavix,
morphine, heparin gtt, integrillin gtt and brought to cath lab.
Temporary Wenkebach noted (no rhythm strips available).  In cath
lab, given 1 mg Atropine with improvement in BP and HR but
converted to A fib per cath report.  Cath revealed 2VD with mLAD
80% s/p 2 cypher stents and dLCx 80-90% s/p PTCA.  RHC showed RA
10, RV 45/10, PCWP 22, CO 4.5, CI 2.3 L/min/m2 and LVEF 45-50%.
Angioseal placed.  Patient denied CP, SOB after cath.
.
ROS negative for DOE, orthopnea, PND or LE edema.


Past Medical History:
PMH:
- HTN
- CAD s/p MI with PTCA ? to PDA in [**2117**]
- GERD (hiatal hernia x 35 years)
- MVP
- PVCs, ectopy
- seminoma s/p L orchiectomy


Social History:
- lives in [**Location 49506**], here in [**Location (un) 86**] visiting son.  Originally
from South [**Country 480**].  Denies tobacco use, occ EtOH.
- walks 3 km 3x/week

Family History:
- Father CAD s/p MI and death age 76
- Mom - colon CA age 81
- Sister - CAD
- Brother - HTN


Physical Exam:
T 97.7  BP 116/52 HR 84 15 100% on 2L NC
Drips: integrillin
GEN - NAD, A&Ox3
HEENT - PERRL, EOMI, OP clear
NECK - JVD 10 cm, supple, no LAD
HEART - regularly irregular, normal rate, no mrg
LUNGS - CTAB anterlaterally
ABD - soft, NT/ND, NABS
EXT - no edema
.


Pertinent Results:
[**2128-7-14**] 08:21PM   LACTATE-1.6
[**2128-7-14**] 05:13PM   GLUCOSE-124* UREA N-11 CREAT-0.8 SODIUM-135
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-13
[**2128-7-14**] 05:13PM   CK(CPK)-1747*
[**2128-7-14**] 05:13PM   CK-MB-142* MB INDX-8.1* cTropnT-3.15*
[**2128-7-14**] 05:13PM   CALCIUM-8.0* PHOSPHATE-2.8 MAGNESIUM-1.8
[**2128-7-14**] 05:13PM   HCT-31.4*
[**2128-7-14**] 11:00AM   CK(CPK)-2602*
[**2128-7-14**] 11:00AM   CK-MB-258* MB INDX-9.9* cTropnT-6.41*
[**2128-7-14**] 11:00AM   PLT COUNT-228
[**2128-7-14**] 01:12AM   ALT(SGPT)-41* AST(SGOT)-195* CK(CPK)-2123*
ALK PHOS-67 AMYLASE-74 TOT BILI-0.8
[**2128-7-14**] 01:12AM   LIPASE-24
[**2128-7-14**] 01:12AM   WBC-11.2* RBC-4.05* HGB-12.3* HCT-35.2*
MCV-87 MCH-30.3 MCHC-34.8 RDW-13.2
[**2128-7-13**] 07:40PM   D-DIMER-360
[**2128-7-13**] 07:40PM   PT-12.6 PTT-27.7 INR(PT)-1.1

CXR [**2128-7-13**]
IMPRESSION: No evidence of an acute cardiopulmonary abnormality.

EKG [**2128-7-13**]
Sinus rhythm
Bigeminal PACs
Left axis deviation
Lateral ST-T changes are nonspecific
No previous tracing
EKG [**2128-7-13**]
Sinus rhythm
Ventricular couplets
Long QTc interval
Left axis deviation
Intraventricular conduction delay
Anterior ST segment elevation may be due to injury
Lateral ST-T changes offer additional evidence of ischemia
Changes may be due to metabolic effect
Since previous tracing of [**2128-7-13**], ST segment elevation and
ventricular
premature complex are new
Clinical correlation is suggested

Catherterization [**2128-7-13**]
1.  Coronary angiography of this right dominant system revealed
severe
two vessel coronary artery disease.  The left main coronary
artery had a
20% stenosis.  The LAD had an 80% stenosis in the mid-vessel and
a small
D2 had an 80% ostial stenosis.  The LCX had a 90% stenosis in
the mid to
distal segment.  The RCA had mild diffuse luminal
irregularities.
2.  Resting hemodynamics revealed mildly to moderately elevated
right
sided filling pressures (mean RA pressure was 8 mm Hg and RVEDP
was 12
mm Hg).  Pulmonary artery pressures were mildly to moderately
elevated
(PA pressure was 40/20 mm Hg).  Left sided filling pressures
were
moderately elevated (mean PCW pressure was 22 mm Hg and LVEDP
was 25 mm
Hg).  Central arterial pressure was normal (aortic pressure was
121/76
mm Hg).  Cardiac index was mildly depressed (at 2.3 L/min/m2).
There
was no significant gradient upon pullback of the catheter from
the left
ventricle to the ascending aorta.
3.  Left ventriculography revealed an ejection fraction of 45%
with
anterolateral hypokinesis.  No mitral regurgitation was noted.
4.  Successful PTCA and stenting of the LAD with two overlapping
3.0 mm
Cypher drug-eluting stents. Final angiography showed no residual

stenosis, no dissection and normal flow (see PTCA comments).
5.  Successful PTCA of the LCX with a 2.0 mm balloon. Final
angiography
showed a 20% residual stenosis, no dissection and normal flow
(see PTCA
comments).
6.  Successful closure of right femoral arteriotomy with
AngioSeal
device.

ECHO [**2128-7-14**]
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal
interatrial septum.  No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderately
depressed LVEF. No resting LVOT gradient. No LV mass/thrombus.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Overall left ventricular systolic
function is moderately depressed with hypokinesisi of the mid to
distal anterior wall, septum and apex. No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Moderately reduced LVEF will regional dysfunction
c/w CAD

[**2128-7-14**] Abdominal U/S
IMPRESSION:
1. No abdominal aortic aneurysm.
2. The gallbladder contains tiny echogenic foci, some of which
likely represent polyps, but a few of which may represent tiny
stones. The gallbladder is otherwise unremarkable.
3. Probable cyst at the liver dome.
4. Simple cyst of the left kidney.

[**2128-7-14**] Abdominal CT
CT OF THE ABDOMEN WITHOUT CONTRAST: There are small bilateral
pleural effusions with minimal bibasilar atelectasis. There are
calcifications seen along the pleural surface of the right lung
base suggesting prior infection. The visualized heart and
pericardium are unremarkable. A low-density rounded focus is
seen within the lateral right lobe of the liver which is
suspicious for a neoplastic implant. A small calcification is
seen within the dome of the liver posteriorly, likely residual
of prior granulomatous infection. No suspicious lesions are
identified within the liver. The gallbladder is filled with oral
contrast and is unremarkable. The stomach wall appears mildly
thickened. The spleen, adrenal glands, and intra- abdominal
loops of small and large bowel are unremarkable. There is
fullness in the tail of the pancreas. The left kidney contains a
rounded low- density focus, likely a cyst. The right kidney is
unremarkable. Neither kidney displays hydronephrosis. There is
no pathologically enlarged mesenteric or retroperitoneal
lymphadenopathy. There is no free air or free fluid within the
abdomen. Calcifications are seen within the abdominal aorta and
its branches.

CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon,
distal ureters, bladder, prostate, and seminal vesicles are
unremarkable. There is no evidence for free or focal fluid, such
as a retroperitoneal hematoma. There is no pathologically
enlarged inguinal or pelvic lymphadenopathy. Again,
calcifications are seen within the arterial vasculature.
BONE WINDOWS: There are no suspicious lytic or blastic osseous
lesions.
CT REFORMATS: Coronal and sagittal reformatted images confirm
the axial findings.

IMPRESSION:
1. No evidence for retroperitoneal hematoma or evidence of
bleeding within the abdomen or pelvis to explain the patient's
dropping hematocrit.
2. Small subcapsular implant within the liver which is
suggestive of a metastatic disease. In the context of a
thickened gastric wall, this is concerning for gastric
carcinoma. Furtehr evalyuation with endoscopy or upper GI is
recommended.
3. Fullness within the pancreatic tail. A mass cannot be
excluded on this no- contrastenhanced examination and contrast
enhanced CT scan is recommended to definitively characterize
this.
4. Small bilateral pleural effusions with minimal bibasilar
atelectasis.




Brief Hospital Course:
1) STEMI - Mr. [**Known lastname 951**] presented with epigastric pain that evolved
to 10/10 chest pain, treated with SLNG.  The chest pain
recurred, accompanied by sweating and hypotension, and he was
noted to have ST elevations in anterior leads and increased
troponins.  He was taken emergently to cath where he was found
to have 2 vessel disease with mLAD 80% stenosis s/p 2 cypher
stents and dLCx 80-90% stenosis s/p PTCA.  RHC showed mildly
elevated filling pressures and normal CO/CI, with a LVEF of
45-50% (see report).  Post cath course was complicated by
hypotension and bradycardia, though to be d/t vagal surge, and
required atropine to maintain hemodynamics.  CK peaked at 2602.
Patient was placed on appropriate CAD medications including ASA,
atorvastatin, metoprolol, captopril, and plavix.  No
anticoagulation was intitiated d/t an EF >40.

2) Epigastric pain - Mr. [**Known lastname 951**] presented initially with
epigastric pain, but this resolved during cath.  The pain
returned shortly after catheterization, accompanied by nausea,
bradycardia, and hypotension.  Laboratory evaluation of the
epigastric pain revealed normal transaminases, amylase, and
lipase.  An abdominal U/S was unremarkable.  Stress dose PPI's
gave little relief, and continued epigastric pain in the setting
of a falling HCT precipited an abdominal CT, which demonstrated
no RP hematoma or evidence of bleed.  However, a lesion within
the liver was documented, as well as a thickened gastric wall
and fullness within the pancreatic tail (see reports).  The
findings were discussed with the patient and it was decided that
he would follow up with his PCP in [**Name9 (PRE) 49506**] to further evaluate
the abdominal CT findings.  At the time of discharge the patient
was pain free on a pantoprazole 40 mg PO and sucralfate.

3) FEN - Hyponatremia to a Na of 130 was thought to be d/t
either SIADH in the setting of acute pain/epigastric discomfort
(supported by Uosm>100) or dehydration (UNa>20).  The patient
was free water restricted and monitored closely and his Na had
improved by discharge.  No symptoms of hyponatremia noted.  Mr.
[**Known lastname **] diet was progressed slowly after resolution of
epigastric discomfort, and he was couseled regarding the
importance of a heart healthy diet.

4) Code - Full

5) Dispo - PT saw the patient prior to discharge.  He will go
home with family and return to [**Location (un) 49506**] in approximately 1
week, where he will follow up with his own physicians regarding
his cardiac and GI issues.



Medications on Admission:
Aspirin 75 mg po qd
Norvasc 5 mg po qd
Zantac prn

Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
STEMI with 2 vessel disease to LAD and LCx


Discharge Condition:
Good

Discharge Instructions:
1) Please take all of your medications as prescribed
2) Please call if you have chest pain, worsening shortness of
breath while active, shortness of breath at rest, weight gain >
5 lbs, edema of lower extremeties, fever, or worsening
epigastric pain.


Followup Instructions:
1) Cardiology - Make an appointment with your cardiologist at
home in [**2-19**] weeks to discuss all of your medications and any
symptoms that you may have.
2) PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] an appointment with your PCP at home in [**2-19**] weeks
to discuss any symptoms that you may have, as well as the
findings on abdominal CT scan so that you may decide if further
workup is warranted/desired.
{'Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Hyposmolality and/or hyponatremia,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia, unspecified,Disorders of phosphorus metabolism,Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract,Unspecified essential hypertension,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease,Family history of malignant neoplasm of gastrointestinal tract,Esophageal reflux,Acquired absence of organ, genital organs'}


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: HPI: 74 yo man with PMH significant for CAD s/p MI and PTCA [**34**]
years ago and HTN presented to ED c/o vague epigastric
discomfort since 1 pm on [**7-13**], which gradually spread across
chest and was [**10-25**] sharp in quality.  Patient called 911.  In
ED, was able to be made pain-free with SLNTG.  Afterwards, SBP
dropped to 80s, but initial EKG without ischemic changes and 1st
set CEs negative.  While in ED, developed sudden onset of sharp
L-sided CP, different from presenting abdominal pain.  Patient
was diaphoretic and SBP down to 70s.  New EKG showed STE
anteriorly --> given fluid boluses and aspirin, plavix,
morphine, heparin gtt, integrillin gtt and brought to cath lab.
Temporary Wenkebach noted (no rhythm strips available).  In cath
lab, given 1 mg Atropine with improvement in BP and HR but
converted to A fib per cath report.  Cath revealed 2VD with mLAD
80% s/p 2 cypher stents and dLCx 80-90% s/p PTCA.  RHC showed RA
10, RV 45/10, PCWP 22, CO 4.5, CI 2.3 L/min/m2 and LVEF 45-50%.
Angioseal placed.  Patient denied CP, SOB after cath.
.
ROS negative for DOE, orthopnea, PND or LE edema.

MEDICAL HISTORY: PMH:
- HTN
- CAD s/p MI with PTCA ? to PDA in [**2117**]
- GERD (hiatal hernia x 35 years)
- MVP
- PVCs, ectopy
- seminoma s/p L orchiectomy

MEDICATION ON ADMISSION: Aspirin 75 mg po qd
Norvasc 5 mg po qd
Zantac prn

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: T 97.7  BP 116/52 HR 84 15 100% on 2L NC
Drips: integrillin
GEN - NAD, A&Ox3
HEENT - PERRL, EOMI, OP clear
NECK - JVD 10 cm, supple, no LAD
HEART - regularly irregular, normal rate, no mrg
LUNGS - CTAB anterlaterally
ABD - soft, NT/ND, NABS
EXT - no edema
.

FAMILY HISTORY: - Father CAD s/p MI and death age 76
- Mom - colon CA age 81
- Sister - CAD
- Brother - HTN

SOCIAL HISTORY: - lives in [**Location 49506**], here in [**Location (un) 86**] visiting son.  Originally
from South [**Country 480**].  Denies tobacco use, occ EtOH.
- walks 3 km 3x/week 

### Response:
{'Acute myocardial infarction of other anterior wall, initial episode of care,Coronary atherosclerosis of native coronary artery,Hyposmolality and/or hyponatremia,Cardiac complications, not elsewhere classified,Other specified cardiac dysrhythmias,Other iatrogenic hypotension,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anemia, unspecified,Disorders of phosphorus metabolism,Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract,Unspecified essential hypertension,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Family history of ischemic heart disease,Family history of malignant neoplasm of gastrointestinal tract,Esophageal reflux,Acquired absence of organ, genital organs'}
