CHIEF COMPLAINT: Chest pain, Shortness of breath

PRESENT ILLNESS: 61 yo male transferred from [**Hospital1 6687**] with chest pain and
concern for STEMI, found to have depressed EF but no
intervenable acute coronary dz, transferred to CCU from cath lab
with hypotension.
   Per report, pt had normal day on [**7-18**], lifted weights in AM
hours - felt fine but admitted to sweating 'much more than
usual.'  After lifiting, had 10 minutes of chest discomfort, not
assoc with breathing, then went away.  Had stable day, no acute
issues, lied on beach and ate 'pounds' of licorice, then went
out with friends, drank 2 bottled Heinekens, went to bed.  Awoke
semi-acutely in AM on day of presentation with shortness of
breath.
   At [**Hospital1 18**], EKG notable for mild st-elevations in I, II, ?STEMI
vs. pericarditis, pt clinically SOB, taken to cath lab.  Cath
showed no acute coronary stenoses, bedside echo showed global
hypokinesis, apex>base, rvedp 12, pcwp 22, CI 1.6.

MEDICAL HISTORY: PMH:
1.  obsessive compulsive disorder
2.  cocaine abuse history (heavy 97-99, intermittemntly
currently)
3.  glaucoma

MEDICATION ON ADMISSION: Klonopin PRN
Lumigan 0.03 % Drops Sig: One (1) Ophthalmic at bedtime.
Istalol 0.5 % Drops, Once Daily Sig: One (1) Ophthalmic qAM.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.6, BP 96/55 on dopa, HR 94, RR 14, 2L 98%
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at jaw angle at 20 degrees elevation in
bed.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  No friction rub.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Father died at age 59 with "hypertensive
cardiomyopathy," reportedly had 'clean cath a month before'
passing.  Mother has no hx of coronary disease, alive, with
dementia.

SOCIAL HISTORY: Significant for the absence of current tobacco use.  +EtOH hx of
'[**3-28**]' drinks per week, mostly beer, with red wine. Pt married,
has three high school/college aged children.  Pt former
emergency room physician in [**Name9 (PRE) 760**], 'retired' a >5 yrs ago,
moved with family to [**Hospital1 6687**].  Now currently works
construction intermittently, sometimes moonlights in ER.
Reports cocaine abuse issue in 97-99, then has used
intermittently.  On initial history today, reported cocaine use
10-14 days ago, ~'1 gram.'   Then on repeat questioning,
reported significant use the day prior to admission.  Pt also
sexually active with multiple female partners over past 2 years,
last tested >1yr ago, was (-).  Has never had STD.
Acute systolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Cocaine abuse, episodic,Other specified hypotension,Unspecified disorder of kidney and ureter,Obsessive-compulsive disorders,Unspecified glaucoma,Family history of other cardiovascular diseases
Ac systolic hrt failure,Acute respiratry failure,Prim cardiomyopathy NEC,Cocaine abuse-episodic,Hypotension NEC,Renal & ureteral dis NOS,Obsessive-compulsive dis,Glaucoma NOS,Fam hx-cardiovas dis NEC
Admission Date:  [**2142-7-19**]              Discharge Date:   [**2142-7-23**]

Date of Birth:  [**2080-9-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 134**]
Chief Complaint:
Chest pain, Shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
61 yo male transferred from [**Hospital1 6687**] with chest pain and
concern for STEMI, found to have depressed EF but no
intervenable acute coronary dz, transferred to CCU from cath lab
with hypotension.
   Per report, pt had normal day on [**7-18**], lifted weights in AM
hours - felt fine but admitted to sweating 'much more than
usual.'  After lifiting, had 10 minutes of chest discomfort, not
assoc with breathing, then went away.  Had stable day, no acute
issues, lied on beach and ate 'pounds' of licorice, then went
out with friends, drank 2 bottled Heinekens, went to bed.  Awoke
semi-acutely in AM on day of presentation with shortness of
breath.
   At [**Hospital1 18**], EKG notable for mild st-elevations in I, II, ?STEMI
vs. pericarditis, pt clinically SOB, taken to cath lab.  Cath
showed no acute coronary stenoses, bedside echo showed global
hypokinesis, apex>base, rvedp 12, pcwp 22, CI 1.6.

On review of symptoms, he 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. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.  Cardiac review of systems is
notable for absence of chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.


Past Medical History:
PMH:
1.  obsessive compulsive disorder
2.  cocaine abuse history (heavy 97-99, intermittemntly
currently)
3.  glaucoma

Cardiac Risk Factors: (-) Diabetes, Dyslipidemia, Hypertension


CURRENT MEDICATIONS:
1.  Klonopin prn

ALLERGIES: seasonal allergies

Social History:
Significant for the absence of current tobacco use.  +EtOH hx of
'[**3-28**]' drinks per week, mostly beer, with red wine. Pt married,
has three high school/college aged children.  Pt former
emergency room physician in [**Name9 (PRE) 760**], 'retired' a >5 yrs ago,
moved with family to [**Hospital1 6687**].  Now currently works
construction intermittently, sometimes moonlights in ER.
Reports cocaine abuse issue in 97-99, then has used
intermittently.  On initial history today, reported cocaine use
10-14 days ago, ~'1 gram.'   Then on repeat questioning,
reported significant use the day prior to admission.  Pt also
sexually active with multiple female partners over past 2 years,
last tested >1yr ago, was (-).  Has never had STD.

Family History:
There is no family history of premature coronary artery disease
or sudden death. Father died at age 59 with "hypertensive
cardiomyopathy," reportedly had 'clean cath a month before'
passing.  Mother has no hx of coronary disease, alive, with
dementia.


Physical Exam:
VS: T 98.6, BP 96/55 on dopa, HR 94, RR 14, 2L 98%
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at jaw angle at 20 degrees elevation in
bed.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  No friction rub.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP



Pertinent Results:
EKG on admission notable for mild st-elevations in I, II with
concern for STEMI vs. pericarditis.  A subsequent EKG showed ST
segment elevations in leads I, aVL and V5-V6 which were
consistent with acute lateral myocardial ischemic process. An
EKG with right-sided chest leads demonstrated no evidence of
right ventricular transmural ischemia. The final EKG done on
[**7-19**] showed persistent ST segment elevation in leads I and aVL.
The ST segment elevation previously recorded in leads V5-V6 had
resolved. EKG on [**7-20**] demonstrated prominent T wave inversions
in leads V4-V6 with
biphasic T waves in leads V2-V3 and T wave inversions in the
inferior leads
suggestive of anterior and inferior ischemia. Compared to the
previous tracing of [**2142-7-19**] the anterior T wave abnormalities
are new.
.
ETT performed on [**2142-7-19**] demonstrated - The left atrium is
normal in size. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is severe global
left ventricular hypokinesis (LVEF = 15-20 %). Right ventricular
chamber size is normal with mild global free wall hypokinesis.
The number of aortic valve leaflets cannot be determined. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
.
Echo on [**2142-7-21**]- Compared with the prior study of [**2142-7-19**]
showed left and right ventricular systolic function are markedly
improved. The left atrium is mildly elongated. There is mild
regional left ventricular systolic dysfunction with very mild
hypokinesis of the distal septum and anterior walls. The
remaining segments contract normally and overall systolic
function is preserved (LVEF = 55-60 %). The estimated CI is
normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size is normal with focal hypokinesis of the apical free
wall. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
CARDIAC CATH performed on [**7-19**] demonstrated:
Coronary angiography of this right dominant system revealed
nonobstructive coronary artery disease.  The LMCA and LCx were
without
angiographically evident flow limiting stenosis.  The LAD had a
40%
lesion after D1.  The RCA had a 30% mid vessel lesion.
Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 12 mm Hg and mean PCWP 22 Hg.  PASP was
elevated
at 42 mm Hg.  Systemic arterial pressure was low at 70-80 mm Hg
with MAP
46 mm Hg.  Cardiac index was depressed at 1.64 mm Hg.
.
HEMODYNAMICS:  elevated pcwp 20, CI 1.6
.
LABORATORY DATA:
CXR [**7-20**]: FINDINGS: The cardiac silhouette remains at the upper
limits of normal. No convincing evidence of vascular congestion.
However,
there is some increasing prominence of the azygos vein region,
raising the
possibility of some right-sided heart failure.
.
[**2142-7-20**] 04:15AM BLOOD CK(CPK)-215*
[**2142-7-19**] 12:36PM BLOOD CK(CPK)-359*
[**2142-7-20**] 04:15AM BLOOD CK-MB-11* MB Indx-5.1
[**2142-7-19**] 12:36PM BLOOD CK-MB-33* MB Indx-9.2*
[**2142-7-19**] 04:25AM BLOOD cTropnT-1.05*
[**2142-7-19**] 04:25AM BLOOD CK-MB-49* MB Indx-9.7* proBNP-3913*
.
[**2142-7-19**] URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-POS
amphetm-NEG mthdone-NEG
[**2142-7-19**] ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
.
[**2142-7-19**] WBC-19.5* RBC-5.17 Hgb-15.5 Hct-44.2 MCV-86 MCH-29.9
MCHC-35.0 RDW-13.2 Plt Ct-344
[**2142-7-22**] WBC-6.0 RBC-4.23* Hgb-12.6* Hct-36.8* MCV-87MCH-29.7
MCHC-34.1 RDW-13.1 Plt Ct-205
.
[**2142-7-19**] PT-13.7* PTT-28.3 INR(PT)-1.2*
[**2142-7-22**] PT-12.5 PTT-22.7 INR(PT)-1.1
.
[**2142-7-19**] Calcium-8.8 Phos-3.7 Mg-1.9
[**2142-7-22**] Glucose-89 UreaN-15 Creat-1.1 Na-139 K-3.9 Cl-102
HCO3-29 AnGap-12
.
[**2142-7-19**] ALT-22 AST-67* CK(CPK)-503* AlkPhos-80 TotBili-0.9
[**2142-7-19**] TotProt-7.4 Albumin-4.7 Globuln-2.7
[**2142-7-19**] Ferritn-127
.
[**2142-7-19**] TSH-5.9*
[**2142-7-19**] T4-5.2
.
[**2142-7-19**] 05:38AM BLOOD Type-ART pO2-60* pCO2-44 pH-7.29*
calTCO2-22

Brief Hospital Course:
This is a 61 yo male presenting with shortness of breath and
found to have clinical heart failure without underlying coronary
artery disease in the setting of intermittent cocaine abuse.
During evaluation at an OSH, there was concern for an STEMI and
the patient was transferred to the [**Hospital1 18**] cath lab.  He was found
to have no identifiable coronary disease, but he did have
compromised systolic function with depressed EF and increased
pcwp. The patient was transferred to the CCU with hypotension
requiring pressors which have since been weaned off. The patient
was re-echoed and his systolic function improved (LVEF 55-50%)
with only very mild hypokinesis of the distal septum and
anterior walls. Transient systolic dysfunction and subsequent
hypotension was likely secondary to recent cocaine abuse by the
patient.
.
CAD/Ischemia:
The patient did not have a prior history of CAD. Cardiac cath
showed no acute stenoses. During hospitalization, the patient
was started on Lisinopril 2.5mg daily to prevent cardiac
remodeling. Pt was also put on Aspirin 81mg daily for secondary
cardioprotective effects.
 .
Pump:
Cardiac cath revealed a compromised EF (LVEF 15-20%) with a PCWP
of 20.  He was given IV Lasix in the cath lab to help improve
systolic function. CXR on admission showed signs of 'mild CHF.'
He demonstrated cardiogenic failure with a compromised CI at
1.4, and did not meet criteria for Impella support. Initial ECHO
showed akinesis in ant septum, ant free wall and apex,
hypokinesis in inferior septum and inferior wall, normal basal
aspects, LVEF 20-30%, and no effusions or valvular problems. The
patient required a Dopamine drip to maintain cardiac output, and
was eventually weaned once CI and SVR improved. A repeat ECHO on
[**7-21**] showed LVEF improved to 55-60%, CI normal (>2.5), mild
regional LV systolic dysfunction with mild hypokinesis of distal
septum/anterior walls.  Clinical heart failure is likely
secondary to cocaine abuse. Additional workup yielded RPR -, T4
nml. Lyme serology and HIV testing pending.
.
Rhythm - No baseline EKG was available for comparison. However,
pt's rhythm was sinus for duration of hospitalization.
.
Valves - Valves were normal on ECHO.
.
Hypotension - This was likely due to pump failure as described
above, and has since improved.
.
Respiratory failure - On admission, pt had 2L O2 requirements
with CXR findings of mild CHF and no identifiable signs of
infiltrate or other pathology. Respiratory compromise was likely
secondary to pulmonary edema. During hospitalization,
oxygenation rapidly improved and pt was satting well on room air
at discharge.
.
Renal failure - Baseline Cr was elevated upon admission to 1.4.
Pt had received contrast during cath. The slight rise in
creatinine was likely due to poor perfusion. Cr levels have
since normalized.
.
Etoh/cocaine - The pt's actual intake amount of EtOH and cocaine
is unclear but his urine tox screen came back positive.  AST was
mildly elevated at 67, ALT normal at 22, and bili 0.9. In
previous discussions regarding substance abuse problems, the pt
was not interested to talk to anyone during this stay. He has a
psychiatrist who he sees as an outpatient about these issues.
Social work was consulted and gave the patient referrals for
substance abuse options on [**Hospital1 6687**] but the patient prefers to
do one on one counseling with his psychiatrist.
.
Psych- On the day of discharge the primary team was called by
his wife who reported the patient was expressing suicidal
ideation.  When Dr. [**Known lastname 79570**] was asked about this he denied
suicidal ideation and reported he and his wife had one of their
typical arguments and he stated "maybe it would have been better
for you if I had died" which his wife misinterpreted as suicidal
ideation.  Psych was consulted and reported he had no acute
psychiatric contraindication to discharge.  Close follow up was
set up with his psychiatrist Dr. [**Last Name (STitle) **].  Psych also recommended
that Dr. [**Known lastname 79570**] discuss restarting Zoloft with his psychiatrist.
.
Glaucoma- The patient continued his home medications:
Latanoprost and Timolol.
.
FEN - The patient was maintained on a cardiac diet. Electrolytes
were repleted as necessary, and the patient was diuresed
intermittently with Lasix to maintain euvolemia.
.
Code - Pt is FULL CODE.

Medications on Admission:
Klonopin PRN
Lumigan 0.03 % Drops Sig: One (1) Ophthalmic at bedtime.
Istalol 0.5 % Drops, Once Daily Sig: One (1) Ophthalmic qAM.


Discharge Medications:
1. Lumigan 0.03 % Drops opthalmic once daily at bedtime.
2. Istalol 0.5 % Drops opthalmic Once daily qAM.
3. Aspirin 81 mg PO DAILY.
4. Klonopin Oral (resume home dosing)
5. Lisinopril 2.5 mg PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
1. Non-ischemic cardiomyopathy secondary to cocaine
2. Substance abuse

Secondary:
1. Glaucoma


Discharge Condition:
Good


Discharge Instructions:
You were admitted to [**Hospital1 18**] for chest pain with compromised
systolic heart function. The etiology of the dysfunction is
unclear, but is likely related to your drug abuse.

The following new medications have been started:
-Lisinopril 2.5mg daily for heart and blood pressure
-Aspirin 81mg daily for secondary cardiovascular protection
.
You were evaluated by inpatient psychiatry and they have
suggested that you may benefit from restarting the Zoloft.
Please discuss this with your psychiatrist at your next follow
up appointment.

If you develop cheset pain, jaw pain, or chest pressure with
pain radiating into arm, or if you have any concerns about your
medical condition, please call 911 or present to the nearest ED.
.
It is also recommended that you have a lipid panel blood test
collected and have results faxed to your PCP. [**Name10 (NameIs) **] is important
to assess your need for a cholesterol-lowering drug.


Followup Instructions:
Please make an appointment to follow-up with:
1. Cardiology: You have a follow up appointment with Dr. [**Last Name (STitle) 3302**]
on Wednesday [**8-8**] at 1pm.  [**Hospital Ward Name 23**] Building, [**Location (un) 436**].
Call [**Telephone/Fax (1) 62**] with any questions.

2. PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]: Tuesday [**7-31**] at 1:30pm. [**Street Address(2) 79571**], [**Hospital1 6687**]. [**Telephone/Fax (1) 38070**].  Please call
[**Telephone/Fax (1) 66939**] to register prior to this appointment.

3. Psychiatrist: Dr. [**Last Name (STitle) **]: Wednesday [**7-25**] at 3pm in ER.
This apppointment is only to touch base.  Please schedule a
routine appointment (call [**Telephone/Fax (1) 79572**]) for Monday [**7-30**].



Completed by:[**2142-8-15**]
{'Acute systolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Cocaine abuse, episodic,Other specified hypotension,Unspecified disorder of kidney and ureter,Obsessive-compulsive disorders,Unspecified glaucoma,Family history of other cardiovascular diseases'}


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, Shortness of breath

PRESENT ILLNESS: 61 yo male transferred from [**Hospital1 6687**] with chest pain and
concern for STEMI, found to have depressed EF but no
intervenable acute coronary dz, transferred to CCU from cath lab
with hypotension.
   Per report, pt had normal day on [**7-18**], lifted weights in AM
hours - felt fine but admitted to sweating 'much more than
usual.'  After lifiting, had 10 minutes of chest discomfort, not
assoc with breathing, then went away.  Had stable day, no acute
issues, lied on beach and ate 'pounds' of licorice, then went
out with friends, drank 2 bottled Heinekens, went to bed.  Awoke
semi-acutely in AM on day of presentation with shortness of
breath.
   At [**Hospital1 18**], EKG notable for mild st-elevations in I, II, ?STEMI
vs. pericarditis, pt clinically SOB, taken to cath lab.  Cath
showed no acute coronary stenoses, bedside echo showed global
hypokinesis, apex>base, rvedp 12, pcwp 22, CI 1.6.

MEDICAL HISTORY: PMH:
1.  obsessive compulsive disorder
2.  cocaine abuse history (heavy 97-99, intermittemntly
currently)
3.  glaucoma

MEDICATION ON ADMISSION: Klonopin PRN
Lumigan 0.03 % Drops Sig: One (1) Ophthalmic at bedtime.
Istalol 0.5 % Drops, Once Daily Sig: One (1) Ophthalmic qAM.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.6, BP 96/55 on dopa, HR 94, RR 14, 2L 98%
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP at jaw angle at 20 degrees elevation in
bed.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.  No friction rub.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death. Father died at age 59 with "hypertensive
cardiomyopathy," reportedly had 'clean cath a month before'
passing.  Mother has no hx of coronary disease, alive, with
dementia.

SOCIAL HISTORY: Significant for the absence of current tobacco use.  +EtOH hx of
'[**3-28**]' drinks per week, mostly beer, with red wine. Pt married,
has three high school/college aged children.  Pt former
emergency room physician in [**Name9 (PRE) 760**], 'retired' a >5 yrs ago,
moved with family to [**Hospital1 6687**].  Now currently works
construction intermittently, sometimes moonlights in ER.
Reports cocaine abuse issue in 97-99, then has used
intermittently.  On initial history today, reported cocaine use
10-14 days ago, ~'1 gram.'   Then on repeat questioning,
reported significant use the day prior to admission.  Pt also
sexually active with multiple female partners over past 2 years,
last tested >1yr ago, was (-).  Has never had STD. 

### Response:
{'Acute systolic heart failure,Acute respiratory failure,Other primary cardiomyopathies,Cocaine abuse, episodic,Other specified hypotension,Unspecified disorder of kidney and ureter,Obsessive-compulsive disorders,Unspecified glaucoma,Family history of other cardiovascular diseases'}
