CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: This patient is a 74 year old male with PMH of HTN,
hyperlipidemia, previous coronary stenting, and angina who
complains of chest pain. At 10pm, while eating dinner pt felt
sharp substernal chest pain ([**6-8**]) that lasted 1min before it
resolved with nitro. Pt reports pain radiated to back during
this time also. He denies any SOB w/ this episode. No n/v. No
arm or back pain. No diaphoresis. Similar episode happened last
week and the pt went into the ED at an OSH for this also.
The pt was admitted to overnight obs in the ED considering
unchanged EKG and negative trop/CKMB. Pt has received aspirin in
the ED yesterday. Repeat EKG this AM, showed T waves flipped.

MEDICAL HISTORY: Coronary Artery Disease
PMH:
Dyslipidemia
Hypertension
Obesity
Current Tobacco
LBBB
Severe Back Pain s/p L4-L5 Hemilaminectomy
Cystoscopy x 2
Kidney stones
COPD
Sleep Apnea - no formal studay - does not use CPAP
Iron Deficiency Anemia
Gout
BPH
Chronic Edema
Basal Cell CA
Gallstones
Glucose intolerance
Past Surgical History:
s/p 3 back surgeries including L4-L5 Hemilaminectomy
Deviated Septum s/p surgical repair
Bladder stone removal
Multiple skin cancer removal
Past Cardiac Procedures
s/p PTCI with bare metal stent to proximal LAD on [**2121-1-23**]
Balloon angioplasty of instent restenosis to prox LAD stenosis
in
[**2121-3-23**]

MEDICATION ON ADMISSION: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet

ALLERGIES: OxyContin / Oxycodone

PHYSICAL EXAM: Admission PE

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Resides with wife in [**Name (NI) 392**]. Ambulates with walker due to back
pain.
-Employment:retired security officer.
-Tobacco history: 40 pack years, stopped in 1/[**2120**].
-ETOH:  denies
-Illicit drugs:denies
-wife [**Name (NI) **] (cell) [**Telephone/Fax (1) 92417**]; [**Telephone/Fax (1) 92418**]
Coronary atherosclerosis of native coronary artery,Other emphysema,Other complications due to other cardiac device, implant, and graft,Other fluid overload,Intermediate coronary syndrome,Iron deficiency anemia, unspecified,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Pain in joint, shoulder region,Other left bundle branch block,Gout, unspecified,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Other abnormal glucose,Body Mass Index 34.0-34.9, adult
Crnry athrscl natve vssl,Emphysema NEC,Comp-oth cardiac device,Fluid overload NEC,Intermed coronary synd,Iron defic anemia NOS,Tobacco use disorder,Status-post ptca,Abn react-artif implant,Iatrogenc hypotnsion NEC,BPH w urinary obs/LUTS,Retention urine NOS,Hypertension NOS,Hyperlipidemia NEC/NOS,Obesity NOS,Joint pain-shlder,Left bb block NEC,Gout NOS,Lumbosacral neuritis NOS,Abnormal glucose NEC,BMI 34.0-34.9,adult
Admission Date:  [**2121-5-3**]              Discharge Date:   [**2121-5-12**]

Date of Birth:  [**2046-11-2**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
OxyContin / Oxycodone

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
[**2121-5-4**] cardiac catheterization

[**2121-5-6**]
1. Urgent coronary artery bypass graft x4, left internal
    mammary artery to left anterior descending artery and
    saphenous vein grafts to diagonal, ramus and obtuse
    marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.


History of Present Illness:
This patient is a 74 year old male with PMH of HTN,
hyperlipidemia, previous coronary stenting, and angina who
complains of chest pain. At 10pm, while eating dinner pt felt
sharp substernal chest pain ([**6-8**]) that lasted 1min before it
resolved with nitro. Pt reports pain radiated to back during
this time also. He denies any SOB w/ this episode. No n/v. No
arm or back pain. No diaphoresis. Similar episode happened last
week and the pt went into the ED at an OSH for this also.
The pt was admitted to overnight obs in the ED considering
unchanged EKG and negative trop/CKMB. Pt has received aspirin in
the ED yesterday. Repeat EKG this AM, showed T waves flipped.


Past Medical History:
Coronary Artery Disease
PMH:
Dyslipidemia
Hypertension
Obesity
Current Tobacco
LBBB
Severe Back Pain s/p L4-L5 Hemilaminectomy
Cystoscopy x 2
Kidney stones
COPD
Sleep Apnea - no formal studay - does not use CPAP
Iron Deficiency Anemia
Gout
BPH
Chronic Edema
Basal Cell CA
Gallstones
Glucose intolerance
Past Surgical History:
s/p 3 back surgeries including L4-L5 Hemilaminectomy
Deviated Septum s/p surgical repair
Bladder stone removal
Multiple skin cancer removal
Past Cardiac Procedures
s/p PTCI with bare metal stent to proximal LAD on [**2121-1-23**]
Balloon angioplasty of instent restenosis to prox LAD stenosis
in
[**2121-3-23**]


Social History:
Resides with wife in [**Name (NI) 392**]. Ambulates with walker due to back
pain.
-Employment:retired security officer.
-Tobacco history: 40 pack years, stopped in 1/[**2120**].
-ETOH:  denies
-Illicit drugs:denies
-wife [**Name (NI) **] (cell) [**Telephone/Fax (1) 92417**]; [**Telephone/Fax (1) 92418**]


Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
Admission PE

VS: T= 97.6 BP= 126/78 HR= 59 RR= 18 O2 sat= 98RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: no JVD
CARDIAC: RRR, no r/m/g; distant heart sounds
LUNGS: CTAB, but diminished bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ edema in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.


Pertinent Results:
IMAGING

Cardiac Cath ([**5-4**]):  1) Selective angiography of this right
dominant system demonstrated significant two-vessel coronary
artery disease.  The LMCA had 60% distal vessel stenosis,
similar to its appearance on [**2121-3-23**].  The LAD had 99% in-stent
restenosis at the recent angioplasty site, with high-grade
stenosis of the ostium of the diagonal branch as well.  The
dominant LCx had moderate disease.  The non-dominant RCA was
known to have 100% proximal occlusion from the previous
catheterization on [**2121-1-23**].
2) Limited resting hemodynamics revealed systemic arterial
normotension,
with a central aortic pressure of 121/65 mmHg.
3) The right common femoral artery arteriotomy site was
Angiosealed
after the case.

FINAL DIAGNOSIS:
1. Severe in-stent restenosis of the proximal LAD, involving the
ostium
of the diagonal branch.
2. Cardiac surgery aware and will evaluate the patient.

EKG [**5-3**]: II, III, aVF, V3-6 shows new inverted T waves
EKG ([**5-4**]): showed ST elevation in lead V2 w/ ST depression in
leads V5/V6 and I
.
[**2121-5-6**] Intra-op TEE
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. 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
mildly depressed (LVEF= 40-45 %). The right ventricular cavity
is mildly dilated with borderline normal free wall function. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque . There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.

POST CPB:
1. Transiently severely depressed LV and RV systolci function.
Responsded to epinephrine infusion with global [**Hospital1 **]-ventricular
function improving to baseline.

2. There is mild TR now and mild MR.

3. No other change
.

[**2121-5-12**] 04:25AM BLOOD WBC-7.9 RBC-3.08* Hgb-9.1* Hct-28.3*
MCV-92 MCH-29.5 MCHC-32.1 RDW-12.6 Plt Ct-333
[**2121-5-11**] 06:30AM BLOOD WBC-7.3 RBC-2.79* Hgb-8.4* Hct-25.7*
MCV-92 MCH-30.1 MCHC-32.7 RDW-12.8 Plt Ct-272
[**2121-5-12**] 04:25AM BLOOD UreaN-28* Creat-0.8 Na-138 K-4.4 Cl-99
[**2121-5-10**] 06:30AM BLOOD Glucose-89 UreaN-29* Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-33* AnGap-9

Brief Hospital Course:
MEDICAL COURSE:
ASSESSMENT AND PLAN: 74M w/ HTN, HLP, former tobacco use,
obesity, CAD, s/p PTCI with bare metal stent to proximal LAD on
[**2121-1-23**] (100% RCA occlusion, 60% distal Left main, high grade
LAD lesion with negative flow velocity of left main c/b
occlusion of left diagonal) p/w unstable angina. Chest pain
responded rapidly to nitro making MI less likely especially
given negative troponins x2 upon presentation. Initial EKG
showed no changes, but EKG in ED the morning after showed
inverted T waves in several leads. Planned to treat UA medically
and cath on Monday. On [**5-4**], the pt experienced multiple episodes
of CP in the morning. All relieved w/ SLNG. Trops cont be neg,
but ST elevation seen on EKG in lead V2 w/ ST depression in
V5/6.
.
# CORONARIES: pt w/ BMS to prox LAD s/p recent angioplasty, p/w
likely UA. His medications were optimized by continuing asa 325
daily, imdur 30mg [**Hospital1 **], lisinopril 20mg daily, atenolol 25mg
daily, plavix 75mg daily. simva 40mg daily was changed to
atorvastatin 80mg daily although to note LDL is at goal at 49,
but HDL low at 24. The pt was started on a heparin gtt. The pt
w/ more episodes of angina, all w/ exertion on [**5-4**]. Relieved w/
SLNG, but started on nitro drip given multiple episodes. trop
neg x6, but concern for ischemia given changes in EKG. pt taken
to cath which showed restenosis of prox LAD. CSurg was contact[**Name (NI) **]
for eval for CABG. Plavix was stopped w/ last dose on [**5-4**]. BP
was regulated on nitro gtt.

Pt transferred off Cards service on [**5-6**] after pt sent for CABG.

SURGICAL COURSE:
The patient was brought to the Operating Room on [**2121-5-6**] where
the patient underwent urgent CABG x 4 with Dr. [**First Name (STitle) **].  Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably.  The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support.  He was subsequently re-intubated on POD 1
and weaned and extubated shortly after.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight.  The patient was transferred to
the telemetry floor for further recovery.  Chest tubes and
pacing wires were discontinued without complication.  Foley was
re-inserted for urinary retention.  He will be discharged with
the Foley for a void trial in the future.  The patient was
evaluated by the physical therapy service for assistance with
strength and mobility.  By the time of discharge on POD 6 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics.  The patient was discharged
[**Hospital 1316**] Rehab in good condition with appropriate follow
up instructions.

Medications on Admission:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet

PO Q8H (every 8 hours) as needed for pain.
6. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO once a day.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: take every 5
minutes, if you use more than 2 [**Hospital 4319**] please notify your
physician [**Name Initial (PRE) 2227**].
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of this medication.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day for 3

[**Last Name (Titles) 4319**].


Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezes.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for wheezes.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1)  Mucous
membrane q 1 hr as needed for sore throat.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
15. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 10 days.
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 10
days.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]

Discharge Diagnosis:
Coronary Artery Disease
PMH:
Dyslipidemia
Hypertension
Obesity
Current Tobacco
LBBB
Severe Back Pain s/p L4-L5 Hemilaminectomy
Cystoscopy x 2
Kidney stones
COPD
Sleep Apnea - no formal studay - does not use CPAP
Iron Deficiency Anemia
Gout
BPH
Chronic Edema
Basal Cell CA
Gallstones
Glucose intolerance
Past Surgical History:
s/p 3 back surgeries including  L4-L5 Hemilaminectomy
Deviated Septum s/p surgical repair
Bladder stone removal
Multiple skin cancer removal
Past Cardiac Procedures
s/p PTCI with  bare metal stent to proximal LAD on [**2121-1-23**]
Balloon angioplasty of instent restenosis to prox LAD stenosis
in
[**2121-3-23**]


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 2+


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**Telephone/Fax (1) 170**] Date/Time:[**2121-6-10**]
1:00

Please call to make an appt with:
Cardiologist/PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 7960**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]

Completed by:[**2121-5-12**]
{'Coronary atherosclerosis of native coronary artery,Other emphysema,Other complications due to other cardiac device, implant, and graft,Other fluid overload,Intermediate coronary syndrome,Iron deficiency anemia, unspecified,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Pain in joint, shoulder region,Other left bundle branch block,Gout, unspecified,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Other abnormal glucose,Body Mass Index 34.0-34.9, adult'}


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: This patient is a 74 year old male with PMH of HTN,
hyperlipidemia, previous coronary stenting, and angina who
complains of chest pain. At 10pm, while eating dinner pt felt
sharp substernal chest pain ([**6-8**]) that lasted 1min before it
resolved with nitro. Pt reports pain radiated to back during
this time also. He denies any SOB w/ this episode. No n/v. No
arm or back pain. No diaphoresis. Similar episode happened last
week and the pt went into the ED at an OSH for this also.
The pt was admitted to overnight obs in the ED considering
unchanged EKG and negative trop/CKMB. Pt has received aspirin in
the ED yesterday. Repeat EKG this AM, showed T waves flipped.

MEDICAL HISTORY: Coronary Artery Disease
PMH:
Dyslipidemia
Hypertension
Obesity
Current Tobacco
LBBB
Severe Back Pain s/p L4-L5 Hemilaminectomy
Cystoscopy x 2
Kidney stones
COPD
Sleep Apnea - no formal studay - does not use CPAP
Iron Deficiency Anemia
Gout
BPH
Chronic Edema
Basal Cell CA
Gallstones
Glucose intolerance
Past Surgical History:
s/p 3 back surgeries including L4-L5 Hemilaminectomy
Deviated Septum s/p surgical repair
Bladder stone removal
Multiple skin cancer removal
Past Cardiac Procedures
s/p PTCI with bare metal stent to proximal LAD on [**2121-1-23**]
Balloon angioplasty of instent restenosis to prox LAD stenosis
in
[**2121-3-23**]

MEDICATION ON ADMISSION: 1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
5. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet

ALLERGIES: OxyContin / Oxycodone

PHYSICAL EXAM: Admission PE

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Resides with wife in [**Name (NI) 392**]. Ambulates with walker due to back
pain.
-Employment:retired security officer.
-Tobacco history: 40 pack years, stopped in 1/[**2120**].
-ETOH:  denies
-Illicit drugs:denies
-wife [**Name (NI) **] (cell) [**Telephone/Fax (1) 92417**]; [**Telephone/Fax (1) 92418**] 

### Response:
{'Coronary atherosclerosis of native coronary artery,Other emphysema,Other complications due to other cardiac device, implant, and graft,Other fluid overload,Intermediate coronary syndrome,Iron deficiency anemia, unspecified,Tobacco use disorder,Percutaneous transluminal coronary angioplasty status,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Retention of urine, unspecified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obesity, unspecified,Pain in joint, shoulder region,Other left bundle branch block,Gout, unspecified,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Other abnormal glucose,Body Mass Index 34.0-34.9, adult'}
