CHIEF COMPLAINT: Shortness of breath and throat tightness

PRESENT ILLNESS: 60 yo F with DMII, HTN, and HL who presented to [**Hospital3 3765**]
yesterday with severe dyspnea and throat tightness. She had been
at the country club when she began to notice shortness of
breath, which became severe quickly. She drove to the fire
station, where EMS was called and she was brought to [**Hospital1 **]. In
the ED, she was thought to be in flash pulmonary edema, and
found to have an NSTEMI with elevated troponins. She was given
lasix, nitro and oxygen with improvement in her symptoms. Nitro
drip was started for blood pressure control. A heparin drip was
started for ACS. A TTE was performed showing LVEF of 35% with
global hypokinesis. She was seen by her cardiologist, who
recommended transfer to [**Hospital1 18**] for cath.
On arrival to the CCU, she is feeling well, without significant
dyspnea. She still has some tightness in her throat that has not
improved since the start of her symptoms.

MEDICAL HISTORY: Coronary artery disease
Systolic Congestive heart failure
Type 2 diabetes, complicated by neuropathy, nephropathy,
retinopathy and s/p toe amputation
Hyperlipidemia
Hypertension
Cataracts
Glaucoma
s/p right carpal tunnel release,
s/p right thumb, ring, and little finger trigger finger releases

MEDICATION ON ADMISSION: Simvastatin 20mg qHS
Metformin 1000mg [**Hospital1 **]
Lantus 84 units qHS
Humalog SS up to 150 units daily
Lasix 60mg daily
Ramipril 20mg daily
Alphagan 0.2% eye drops both eyes

ALLERGIES: fluorescein / Shellfish

PHYSICAL EXAM: Admission-
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds
LUNGS: crackles bilateral halfway up lungs
ABD: soft, non tender, obese
EXT: 1+ pitting edema, amputation of R toe, skin breakdown under
R 4th toe
PULSES: 1+ bilateral DP/PT
.
Discharge:
Vitals: 98.1 HR 74 BP 128/58 99% on Room Air
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds, no murmur heard
LUNGS: crackles bilateral bases
ABD: soft, non tender, obese, nondistended
EXT: trace pitting edema, amputation of R toe, skin breakdown
under R 4th toe
PULSES: 2+ bilateral DP/PT

FAMILY HISTORY: - Brother - MI
- Maternal grandfather - MI at age 50
- Maternal uncle - first CABG in [**State 350**]
- Mother - hypothyroid and HTN

SOCIAL HISTORY: Retired administrative assistant. Has a 21 year old daughter.
[**Name (NI) 1351**], lives alone.
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Cardiomyopathy in other diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified cataract,Unspecified glaucoma
Subendo infarct, initial,Ac on chr syst hrt fail,Hyp ht/kd NOS I-IV w hf,Cardiomyopath in oth dis,Crnry athrscl natve vssl,DMII neuro nt st uncntrl,Neuropathy in diabetes,Diabetic retinopathy NOS,Chronic kidney dis NOS,Long-term use of insulin,Hyperlipidemia NEC/NOS,Cataract NOS,Glaucoma NOS
Admission Date:  [**2135-5-19**]              Discharge Date:   [**2135-5-22**]

Date of Birth:  [**2074-11-21**]             Sex:   F

Service: MEDICINE

Allergies:
fluorescein / Shellfish

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Shortness of breath and throat tightness

Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2135-5-20**])

History of Present Illness:
60 yo F with DMII, HTN, and HL who presented to [**Hospital3 3765**]
yesterday with severe dyspnea and throat tightness. She had been
at the country club when she began to notice shortness of
breath, which became severe quickly. She drove to the fire
station, where EMS was called and she was brought to [**Hospital1 **]. In
the ED, she was thought to be in flash pulmonary edema, and
found to have an NSTEMI with elevated troponins. She was given
lasix, nitro and oxygen with improvement in her symptoms. Nitro
drip was started for blood pressure control. A heparin drip was
started for ACS. A TTE was performed showing LVEF of 35% with
global hypokinesis. She was seen by her cardiologist, who
recommended transfer to [**Hospital1 18**] for cath.
On arrival to the CCU, she is feeling well, without significant
dyspnea. She still has some tightness in her throat that has not
improved since the start of her symptoms.

REVIEW OF SYSTEMS
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, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. Cardiac
review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. All of the other review of
systems were negative.

Past Medical History:
Coronary artery disease
Systolic Congestive heart failure
Type 2 diabetes, complicated by neuropathy, nephropathy,
retinopathy and s/p toe amputation
Hyperlipidemia
Hypertension
Cataracts
Glaucoma
s/p right carpal tunnel release,
s/p right thumb, ring, and little finger trigger finger releases


Social History:
Retired administrative assistant. Has a 21 year old daughter.
[**Name (NI) 1351**], lives alone.
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None

Family History:
- Brother - MI
- Maternal grandfather - MI at age 50
- Maternal uncle - first CABG in [**State 350**]
- Mother - hypothyroid and HTN

Physical Exam:
Admission-
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds
LUNGS: crackles bilateral halfway up lungs
ABD: soft, non tender, obese
EXT: 1+ pitting edema, amputation of R toe, skin breakdown under
R 4th toe
PULSES: 1+ bilateral DP/PT
.
Discharge:
Vitals: 98.1 HR 74 BP 128/58 99% on Room Air
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds, no murmur heard
LUNGS: crackles bilateral bases
ABD: soft, non tender, obese, nondistended
EXT: trace pitting edema, amputation of R toe, skin breakdown
under R 4th toe
PULSES: 2+ bilateral DP/PT

Pertinent Results:
Admission-
[**2135-5-19**] 07:43PM BLOOD WBC-7.3 RBC-3.94* Hgb-11.0* Hct-34.5*
MCV-88 MCH-27.9 MCHC-31.8 RDW-14.0 Plt Ct-178
[**2135-5-19**] 07:43PM BLOOD PT-11.8 PTT-59.7* INR(PT)-1.1
[**2135-5-19**] 07:43PM BLOOD Glucose-201* UreaN-30* Creat-1.1 Na-135
K-3.7 Cl-98 HCO3-24 AnGap-17
[**2135-5-19**] 07:43PM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 Cholest-161
[**2135-5-19**] 07:43PM BLOOD %HbA1c-6.9* eAG-151*
[**2135-5-19**] 07:43PM BLOOD HDL-42 CHOL/HD-3.8 LDLmeas-96

Cardiac Enzymes-
[**2135-5-19**] 07:43PM BLOOD CK(CPK)-998* CK-MB-37* MB Indx-3.7
cTropnT-1.71*
[**2135-5-20**] 05:19AM BLOOD CK(CPK)-874* CK-MB-21* MB Indx-2.4
[**2135-5-21**] 05:54AM BLOOD CK(CPK)-427* CK-MB-8
.
Preliminary cath report:
1. Selective coronary angiogaphy in this left dominant system
demonstrated 2 vessel coronary artery disease.  The coronary
arteries were heavily calcified.  The LMCA was patent. The LAD
was a small vessel with luminal irregularities, but was free of
angiographically obstructive coronary artery disease.  The LCX
had a 80% proximal lesion in a tortuous segment prior to a large
OM branch.  The RCA was a small non-dominant vessel that was
diffusely diseased, including at the ostium.  The RCA also had a
subtotal occlusion in the proximal segment. After review of the
angiogram and considation of the patient's diabetes, patent LAD,
small non-dominant RCA, and tortuous proximal LCX which would
not necessarily be easily navigable with a stent or balloon, it
was decided that medical management would be the best option.
2. Limited resting hemodynamics revealed mild systemic arterial
hypertension with a central aortic blood pressure of 140/66.
The LVEDP was severely eleveated at 31 mmHg.
3. The right femoral artery was closed with a 5 french ExoSeal.

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severely elevated LVEDP consistent with systolic heart
failure.
3. Mild systemic arterial hypertension.
4. Right femoral artery closed with ExoSeal device.
.
[**5-29**] EKG:
Baseline artifact. Sinus rhythm with a single ventricular
premature beat.  Borderline voltage for left ventricular
hypertrophy in lead aVL. ST-T wave abnormalities. Consider
strain/ischemia. Borderline low precordial voltage. No previous
tracing available for comparison. Clinical correlation is
suggested.
.
Discharge labs:

[**2135-5-22**] 10:40AM BLOOD WBC-8.0 RBC-4.37 Hgb-12.7 Hct-40.5 MCV-93
MCH-28.9 MCHC-31.3 RDW-14.0 Plt Ct-230
[**2135-5-20**] 05:19AM BLOOD PT-11.4 PTT-69.2* INR(PT)-1.1
[**2135-5-22**] 10:40AM BLOOD Glucose-140* UreaN-46* Creat-1.1 Na-140
K-5.4* Cl-101 HCO3-25 AnGap-19
[**2135-5-22**] 02:45PM BLOOD Na-140 K-4.4 Cl-102
[**2135-5-22**] 10:40AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.4
[**2135-5-19**] 07:43PM BLOOD %HbA1c-6.9* eAG-151*
[**2135-5-19**] 07:43PM BLOOD HDL-42 CHOL/HD-3.8 LDLmeas-96

Brief Hospital Course:
SUMMARY:  60 y/o F with Type 2 DM, HTN, and HL who presented to
an OSH with shortness of breath and throat tightness,
transferred to [**Hospital1 18**] for management of NSTEMI and acute CHF
exacerbation.
.
# NSTEMI:  Cardiac cath showed LCx and RCA disease with patent
LAD.  Recommendation was made for aggressive medical management.
 Patient was started on aspirin 81mg daily as patient previously
unable to tolerate higher dose secondary to GI intolerance.  She
was initiated on metoprolol, and her simvastatin was increased
to 40mg daily (patient unable to tolerate atorvastatin in the
past).  Given her decreased blood pressure after initiation of
metoprolol, her ramipril dose was decreased.  Of note, her
throat tightness may be her anginal equivalent.
.
# Acute exacerbation of Congestive Heart Failure:  TTE at OSH
showed LVEF of 35% with global hypokinesis, and the etiology of
her acute exacerbation is likely secondary to ACS.  She was
initially diuresed with IV lasix, which was transitioned to home
PO lasix prior to discharge.
.
# Type II DM: Long-term diabetes complicated by neuropathy,
nephropathy, and retinopathy. She is s/p toe amputation due to
poor peripheral circulation and neuropathy. HbA1c was 6.9%
indicating good control.  Given her high insulin requirements,
[**Last Name (un) **] was consulted.
.
# Chronic kidney disease: Secondary to long-standing diabetes.
Creatinine stable at 1.1 this admission.
.
# HTN: Treated with metoprolol and ramipril as above
.
# HLD: Simvastatin in lieu of atorvastatin given history of
intolerance.
.
# Vertigo: The patient endorsed symptoms consistent with
peripheral vertigo, which she has had in the past. She was
initiated on meclizine for treatment, and will need follow-up.
.
# Pannus abrasion:  The patient had two small abrasions under
her pannus on the right. Recommended that she follow-up with her
primary doctor, and apply vasoline and cover with gauze or a
bandage to prevent further damage.
.
=======
TRANSITIONAL ISSUES:
-Titrate ramipril and metoprolol
[**Hospital **] rehabilitation
-Repeat TTE in [**5-6**] weeks
-Monitor abrasions under pannus on right
-Monitor vertigo symptoms, meclizine initiated

Medications on Admission:
Simvastatin 20mg qHS
Metformin 1000mg [**Hospital1 **]
Lantus 84 units qHS
Humalog SS up to 150 units daily
Lasix 60mg daily
Ramipril 20mg daily
Alphagan 0.2% eye drops both eyes

Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

3. Lantus 100 unit/mL Solution Sig: Eighty Four (84) units
Subcutaneous at bedtime.
4. Humalog SS up to 150 units daily
5. furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. ramipril 10 mg Capsule Sig: One (1) Capsule PO once a day.
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*0*
10. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Non-ST elevation myocardial infarction
Coronary artery disease
Acute on chronic systolic heart failure
Type 2 diabetes
Hypertension
Hyperlipidemia


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


Discharge Instructions:
You were admitted for a heart attack.  This also caused fluid to
build up in your lungs. We treated you with medications to
reduce blood pressure, heart rate, and to remove the extra fluid
from your lungs.  It will be very, very important to follow-up
closely with your outpatient doctors.  Taking your medications
as prescribed, coupled with a healthy diet and exercise will
help reduce your risk for future problems with your heart.
.
You also have some skin abrasions near your groin area. You
should apply vasoline to these areas and cover with gauze or a
bandage.  You should make sure to show this area to your primary
doctor in follow-up.
.
Please weigh yourself every morning, and call your doctor if
your weight increases by more than 3 pounds.
.
Please note the following medication changes:
-INCREASE simvastatin to 40mg daily to lower your cholesterol

-DECREASE ramipril to 10mg daily

-START Aspirin 81mg daily to help prevent future heart attacks
-START Metoprolol to help lower your heart rate
-START Meclizine to help with vertigo (dizziness)

Followup Instructions:
-Please call your cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 110489**]),
and schedule a follow-up appointment within 7-10 days of
discharge from the hospital.

-Please call your primary care physician, [**Last Name (NamePattern4) **].[**Last Name (LF) **],[**First Name3 (LF) **] D.
([**Telephone/Fax (1) 22235**]) and schedule a follow-up appointment within one
week of discharge from the hospital



Completed by:[**2135-5-22**]
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Cardiomyopathy in other diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified cataract,Unspecified glaucoma'}


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: Shortness of breath and throat tightness

PRESENT ILLNESS: 60 yo F with DMII, HTN, and HL who presented to [**Hospital3 3765**]
yesterday with severe dyspnea and throat tightness. She had been
at the country club when she began to notice shortness of
breath, which became severe quickly. She drove to the fire
station, where EMS was called and she was brought to [**Hospital1 **]. In
the ED, she was thought to be in flash pulmonary edema, and
found to have an NSTEMI with elevated troponins. She was given
lasix, nitro and oxygen with improvement in her symptoms. Nitro
drip was started for blood pressure control. A heparin drip was
started for ACS. A TTE was performed showing LVEF of 35% with
global hypokinesis. She was seen by her cardiologist, who
recommended transfer to [**Hospital1 18**] for cath.
On arrival to the CCU, she is feeling well, without significant
dyspnea. She still has some tightness in her throat that has not
improved since the start of her symptoms.

MEDICAL HISTORY: Coronary artery disease
Systolic Congestive heart failure
Type 2 diabetes, complicated by neuropathy, nephropathy,
retinopathy and s/p toe amputation
Hyperlipidemia
Hypertension
Cataracts
Glaucoma
s/p right carpal tunnel release,
s/p right thumb, ring, and little finger trigger finger releases

MEDICATION ON ADMISSION: Simvastatin 20mg qHS
Metformin 1000mg [**Hospital1 **]
Lantus 84 units qHS
Humalog SS up to 150 units daily
Lasix 60mg daily
Ramipril 20mg daily
Alphagan 0.2% eye drops both eyes

ALLERGIES: fluorescein / Shellfish

PHYSICAL EXAM: Admission-
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds
LUNGS: crackles bilateral halfway up lungs
ABD: soft, non tender, obese
EXT: 1+ pitting edema, amputation of R toe, skin breakdown under
R 4th toe
PULSES: 1+ bilateral DP/PT
.
Discharge:
Vitals: 98.1 HR 74 BP 128/58 99% on Room Air
GEN: obese, well-appearing, no acute distress
HEENT: moist mucus membranes, no erythema or exudate
NECK: supple, no JVD
CV: RRR, distant heart sounds, no murmur heard
LUNGS: crackles bilateral bases
ABD: soft, non tender, obese, nondistended
EXT: trace pitting edema, amputation of R toe, skin breakdown
under R 4th toe
PULSES: 2+ bilateral DP/PT

FAMILY HISTORY: - Brother - MI
- Maternal grandfather - MI at age 50
- Maternal uncle - first CABG in [**State 350**]
- Mother - hypothyroid and HTN

SOCIAL HISTORY: Retired administrative assistant. Has a 21 year old daughter.
[**Name (NI) 1351**], lives alone.
- Tobacco history: Never
- ETOH: None
- Illicit drugs: None 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Hypertensive heart and chronic kidney disease, unspecified, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified,Cardiomyopathy in other diseases classified elsewhere,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Background diabetic retinopathy,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified cataract,Unspecified glaucoma'}
