CHIEF COMPLAINT: ASA desensitization

PRESENT ILLNESS: 65 year old female with no previous history of CAD, GERD, COPD
admitted to [**Hospital6 **] with chest pain, found to have
95-99% LAD bifurcating lesion, transferred to [**Hospital1 18**] for
intervention and ASA desensitization.  Admitted earlier this
week to [**Hospital3 **] for chest pain with negative CT, negative
imaging stress test, and negative nuclear ETT.  Discharged
yesterday ([**10-1**])from [**Hospital3 **], but then brought in by
ambulance to [**Hospital3 **] with recurrent chest pain radiating to
her back and both arms, similar to the symptoms that prompted
her previous admission a few days earlier, CE's negative x 2.
Upon her first admission, she refused cardiac catheterization,
but underwent cath upon the second admission with the above
noted LAD lesion.  Transferred to [**Hospital1 18**] for intervention with
necessity for ASA desensitization due to allergy.  Reported to
be chest pain free, with 5 French in RFA, distal pulses intact.
Loaded with 600 mg plavix and IV heparin/Integrillin. In the
cath lab, DES was placed in the proximal LAD, and is now in the
CCU for aspirin desensitization.
.
Pt denies any current chest pain/discomfort, shortness of
breath, or nausea. She reports back pain due to positioning
secondary to her "sciatica pain" that is starting to sit in her
abdomen.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS:  none
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- GERD
- COPD
- Asthma
- Tubal Pregnancy
- Appendectomy
- Carpal Tunnel Syndrome, finger in splint
- Environmental Allergies
- Left Knee Arthroscopy
- Angina

MEDICATION ON ADMISSION: - Accolate
- Symbicort 160/4.5 2 puffs inh qAM
- Zyrtec
- Nexium 20mg daily
- Nitrostat
- Spiriva 1 puff inh qAM
- Metoprolol 25 mg twice daily
- simvastatin 20 mg daily
- lorazepam 1mg twice daily as needed for anxiety

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / caffeine

PHYSICAL EXAM: Admission Exam
VS: T BP= 147/77 (132-147/73-84) HR= 63 (71-77) RR= 15 (13-26)
O2 sat= 95% (91-95% RA)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: - Has five children, alive and well
- Mother:  healthy
- Father:  deceased, CAD s/p MI in his 60s, cancer, DM,
emphysema

SOCIAL HISTORY: - Tobacco history: [**12-31**] PPD 50+ years
- ETOH:  denies
- Illicit drugs:  denies
Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cardiac complications, not elsewhere classified,Need for desensitization to allergens,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic obstructive asthma, unspecified,Tobacco use disorder,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Crnry athrscl natve vssl,Intermed coronary synd,Surg compl-heart,Desensitiza to allergens,Esophageal reflux,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Chronic obst asthma NOS,Tobacco use disorder,Abn react-cardiac cath
Admission Date:  [**2176-10-2**]              Discharge Date:   [**2176-10-4**]

Date of Birth:  [**2111-1-4**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / caffeine

Attending:[**First Name3 (LF) 2265**]
Chief Complaint:
ASA desensitization

Major Surgical or Invasive Procedure:
placement of DES in LAD with jailing of diagonal vessel

History of Present Illness:
65 year old female with no previous history of CAD, GERD, COPD
admitted to [**Hospital6 **] with chest pain, found to have
95-99% LAD bifurcating lesion, transferred to [**Hospital1 18**] for
intervention and ASA desensitization.  Admitted earlier this
week to [**Hospital3 **] for chest pain with negative CT, negative
imaging stress test, and negative nuclear ETT.  Discharged
yesterday ([**10-1**])from [**Hospital3 **], but then brought in by
ambulance to [**Hospital3 **] with recurrent chest pain radiating to
her back and both arms, similar to the symptoms that prompted
her previous admission a few days earlier, CE's negative x 2.
Upon her first admission, she refused cardiac catheterization,
but underwent cath upon the second admission with the above
noted LAD lesion.  Transferred to [**Hospital1 18**] for intervention with
necessity for ASA desensitization due to allergy.  Reported to
be chest pain free, with 5 French in RFA, distal pulses intact.
Loaded with 600 mg plavix and IV heparin/Integrillin. In the
cath lab, DES was placed in the proximal LAD, and is now in the
CCU for aspirin desensitization.
.
Pt denies any current chest pain/discomfort, shortness of
breath, or nausea. She reports back pain due to positioning
secondary to her "sciatica pain" that is starting to sit in her
abdomen.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS:  none
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- GERD
- COPD
- Asthma
- Tubal Pregnancy
- Appendectomy
- Carpal Tunnel Syndrome, finger in splint
- Environmental Allergies
- Left Knee Arthroscopy
- Angina


Social History:
- Tobacco history: [**12-31**] PPD 50+ years
- ETOH:  denies
- Illicit drugs:  denies

Family History:
- Has five children, alive and well
- Mother:  healthy
- Father:  deceased, CAD s/p MI in his 60s, cancer, DM,
emphysema

Physical Exam:
Admission Exam
VS: T BP= 147/77 (132-147/73-84) HR= 63 (71-77) RR= 15 (13-26)
O2 sat= 95% (91-95% RA)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: No JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB assessed
anteriorly due to venous sheath in place, no crackles, wheezes
or rhonchi.
ABDOMEN: Soft, ND. Slight TTP in the epigastrum region. No HSM
or tenderness. Abd aorta not palpable. No abdominial bruits.
EXTREMITIES: No c/c/e. Venous sheath in right [**Last Name (un) **] in place,
c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+

Discharge exam
VS: T 97.9 BP= 122/67 HR= 78 RR= 18O2 sat= 100% ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: No JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB assessed
anteriorly due to venous sheath in place, no crackles, wheezes
or rhonchi.
ABDOMEN: Soft, NT, ND. No HSM or tenderness. Abd aorta not
palpable. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+ DP 2+ PT 2+
Left: Carotid 2+ Radial 2+ DP 2+ PT 2+


Pertinent Results:
Admission Labs
[**2176-10-2**] 08:41PM BLOOD WBC-13.2* RBC-4.22 Hgb-12.5 Hct-36.3
MCV-86 MCH-29.6 MCHC-34.3 RDW-13.3 Plt Ct-218
[**2176-10-2**] 08:41PM BLOOD PT-14.4* PTT-150* INR(PT)-1.2*
[**2176-10-2**] 08:41PM BLOOD Glucose-163* UreaN-10 Creat-0.7 Na-139
K-3.8 Cl-108 HCO3-16* AnGap-19
[**2176-10-2**] 08:41PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8 Cholest-152
[**2176-10-2**] 08:41PM BLOOD Triglyc-104 HDL-46 CHOL/HD-3.3 LDLcalc-85
[**2176-10-3**] 05:59AM BLOOD CK-MB-84* MB Indx-11.8* cTropnT-0.81*

Discharge Labs
[**2176-10-4**] 06:30AM BLOOD WBC-8.6 RBC-3.95* Hgb-11.9* Hct-34.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.4 Plt Ct-199
[**2176-10-4**] 06:30AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-143
K-4.2 Cl-109* HCO3-25 AnGap-13
[**2176-10-4**] 06:30AM BLOOD CK(CPK)-360*
[**2176-10-4**] 06:30AM BLOOD CK-MB-32* MB Indx-8.9* cTropnT-0.67*
[**2176-10-4**] 06:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
[**2176-10-2**] 08:41PM BLOOD Triglyc-104 HDL-46 CHOL/HD-3.3 LDLcalc-85

Cath report:
1. Coronary angiography in this right dominant system
demonstrated 95%
proximal LAD stenosis involving the origin of a large D1 with
ostial 70%
stenosis. The LMCA, LCx, and RCA had no angiographically
apparent
disease.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with SBP 164 mmHg.
3. Successful PCI of the LAD with 2.5x18mm Promus DES and
overlapping
3.0x8mm Promus post-dilated to 3.0mm distally and 3.25mm
proximally (see
PTCA comments).
4. Procedure complicated by transient closure and dissection of
D1,
which was successfully rescued (see PTCA comments).
5. Manual 8F RFA sheath pull.

FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful PCI of LAD with DES complicated by transient
closure and
dissection of D1 successfully rescued (see PTCA comments).
3. Plavix for minimum 12 months.
4. Aspirin desensitization immediately in CCU per protocol, and
then
continue indefinitely.
5. Integrillin to continue for 18 hours post-PCI.
6. Hydrate for prevention of contrast nephropathy.
7. Check cardiac enzymes and monitor clinical status closely.
8. Manual sheath pull when ACT<170s.

TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with akinesis of the mid to
distal septum and hypokinesis of the apex. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.

IMPRESSION: Normal left ventricular cavity size and wall
thickness with mild regional left ventricular systolic
dysfunction as described above. No clinically significant
valvular disease. Normal pulmonary artery systolic pressure.


Brief Hospital Course:
65F with GERD, COPD with unstable angina with negative cardiac
enzymes found to have 95-99% bifucating LAD lesion now s/p cath
with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in proximal LAD, admitted to CCU for aspirin
desensitization, chest pain free.
.
# Unstable angina:  Presented to OSH with chest pain, negative
enzymes, found to have 80% bifurcating lesion to LAD.
Transferred to [**Hospital1 18**] for intervention. A DES was placed in the
LAD, with jailing of diagonal branch. She remained chest pain
free after the procedure, although cardiac enzymes did rise
(consistent with jailing). Because she has a allergy to aspirin,
she was then transferred to the CCU for aspirin desensitization,
which was successful. She was started on ASA 325mg PO daily,
plavix 75mg PO daily, lisinopril 5mg daily. Metoprolol not
started for the time being as her pressures were in 90's on
lisinopril. PCP or cardiologist can consider starting
beta-blocker in the future. Repeat TTE showed EF45-50% with
akinesis of the mid to distal septum and hypokinesis of the
apex.
.
# ASPIRIN DESENSITIZATION: Reported hives/mouth sensation with
prior use. Transferred briefly to CCU for asa desensitization,
which was successfully completed without incident. She was
started on ASA 325mg PO daily.
.
# COPD - chronic, breathing at baseline throughout admission.
Continued on spiriva and advair-diskus (substituted from
symbicort as that is non-formulary)
.
# SMOKING History - nicotine patch while in-house. Smoking
cessation councelling provided at length. Nicotine patch
prescription given for outpatient setting. She should follow
closely with her PCP regarding smoking cessation.


Medications on Admission:
- Accolate
- Symbicort 160/4.5 2 puffs inh qAM
- Zyrtec
- Nexium 20mg daily
- Nitrostat
- Spiriva 1 puff inh qAM
- Metoprolol 25 mg twice daily
- simvastatin 20 mg daily
- lorazepam 1mg twice daily as needed for anxiety

Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 21 days.
Disp:*21 Patch 24 hr(s)* Refills:*0*
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Symbicort 80-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-31**]
Inhalation 2 puffs () as needed for [**Hospital1 **].
7. pantoprazole 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*
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN chest pain: [**Month (only) 116**] take again after 5 minutes if
chest pain persists, and then a 3rd dose 5 minutes later if
still having chest pain.
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Accolate  Oral
11. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.


Discharge Disposition:
Home

Discharge Diagnosis:
unstable angina s/p DES to LAD with jailing of diagonal artery

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


Discharge Instructions:
Dear Ms [**Known lastname **],

It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for an interventional cardiac procedure to open-up a partially
blocked blood vessel to your heart. This blockage had been
causing you chest pain. A drug eluting stent was placed in this
blood vessel. These stents require that you take aspirin and
clopidogrel (Plavix) for at least one year or possibly longer.
Do not stop taking aspirin and clopidogrel for any reason unless
Dr. [**Last Name (STitle) 33746**] tells you this is OK. You risk clotting off the stent
and causing another heart attack if you do not continue these
medicines. Because aspirin is an important blood thinner, and
you were allergic to it, you had aspirin desensitization. This
was successful and you can now take aspirin and should take this
medicine every day for the rest of your life.

The following changes were made to your medications:
** STOP nexium, take pantoprazole instead for your heartburn.

** START aspirin 325mg by mouth once daily for at least one year
to prevent the stent from clotting off.
** START Plavix (clopidogrel) 75mg by mouth once daily for at
least one year to prevent the stent from clotting off
** START lisinopril 5mg by mouth once daily to lower your blood
pressure
** STOP taking simvastatin, start atorvastatin 80mg by mouth
once daily to lower your cholesterol
** START nicotine patch every day to help you quit smoking. This
is the most important thing you can do for your health.
** STOP taking metoprolol for now, Dr. [**First Name (STitle) **] can restart this
medicine next week if your blood pressure has improved


Followup Instructions:
Pt has appt with Dr. [**First Name (STitle) **] on Tuesday [**10-8**] and Dr. [**First Name (STitle) **] will
arrange for a cardiology appt at that time.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2273**]
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cardiac complications, not elsewhere classified,Need for desensitization to allergens,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic obstructive asthma, unspecified,Tobacco use disorder,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: ASA desensitization

PRESENT ILLNESS: 65 year old female with no previous history of CAD, GERD, COPD
admitted to [**Hospital6 **] with chest pain, found to have
95-99% LAD bifurcating lesion, transferred to [**Hospital1 18**] for
intervention and ASA desensitization.  Admitted earlier this
week to [**Hospital3 **] for chest pain with negative CT, negative
imaging stress test, and negative nuclear ETT.  Discharged
yesterday ([**10-1**])from [**Hospital3 **], but then brought in by
ambulance to [**Hospital3 **] with recurrent chest pain radiating to
her back and both arms, similar to the symptoms that prompted
her previous admission a few days earlier, CE's negative x 2.
Upon her first admission, she refused cardiac catheterization,
but underwent cath upon the second admission with the above
noted LAD lesion.  Transferred to [**Hospital1 18**] for intervention with
necessity for ASA desensitization due to allergy.  Reported to
be chest pain free, with 5 French in RFA, distal pulses intact.
Loaded with 600 mg plavix and IV heparin/Integrillin. In the
cath lab, DES was placed in the proximal LAD, and is now in the
CCU for aspirin desensitization.
.
Pt denies any current chest pain/discomfort, shortness of
breath, or nausea. She reports back pain due to positioning
secondary to her "sciatica pain" that is starting to sit in her
abdomen.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, 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 paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS:  none
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- GERD
- COPD
- Asthma
- Tubal Pregnancy
- Appendectomy
- Carpal Tunnel Syndrome, finger in splint
- Environmental Allergies
- Left Knee Arthroscopy
- Angina

MEDICATION ON ADMISSION: - Accolate
- Symbicort 160/4.5 2 puffs inh qAM
- Zyrtec
- Nexium 20mg daily
- Nitrostat
- Spiriva 1 puff inh qAM
- Metoprolol 25 mg twice daily
- simvastatin 20 mg daily
- lorazepam 1mg twice daily as needed for anxiety

ALLERGIES: Penicillins / Sulfa (Sulfonamide Antibiotics) / caffeine

PHYSICAL EXAM: Admission Exam
VS: T BP= 147/77 (132-147/73-84) HR= 63 (71-77) RR= 15 (13-26)
O2 sat= 95% (91-95% RA)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: - Has five children, alive and well
- Mother:  healthy
- Father:  deceased, CAD s/p MI in his 60s, cancer, DM,
emphysema

SOCIAL HISTORY: - Tobacco history: [**12-31**] PPD 50+ years
- ETOH:  denies
- Illicit drugs:  denies 

### Response:
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Cardiac complications, not elsewhere classified,Need for desensitization to allergens,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Chronic obstructive asthma, unspecified,Tobacco use disorder,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
