CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 53yo gentleman with h/o CAD (2 vessel disease of LCx and
co-dominant RCA), mild systolic CHF (EF 45%), and DM2
transferred from [**Hospital3 417**] with NSTEMI.
Patient reports stuttering exertional and non-exertional chest
pain for anywhere from days to months, depending on the
interviewer. He had dismissed the pain as being due to acid
reflux. Of note, he had stopped taking many of his cardiac
medications (including plavix, metoprolol, lisinopril, and
imdur) without discussing the matter with his PCP. [**Name10 (NameIs) **] finally
came into the hospital at [**Hospital3 **] because his pain did not go
away after a few days despite taking antacids. He also admits to
doing 4 lines of cocaine 2 days prior to presentation. During
his initial work-up at [**Hospital1 **], he was found to have ST
depressions in V5 and V6 with troponin of 3.1, at which point he
was transferred to [**Hospital1 18**]. He received ASA, plavix 300mg, and
lovenox and was on a nitro gtt prior to transfer. He was also on
an amiodarone gtt for reported frequent ectopy.
In the ED, his initial VS were: 97.2 146/85 25 95% 4L. He was
having mild chest pain and frequent runs of NSVT. Cardiology was
consulted for positive biomarkers. He was put on an integrillin
gtt and given morphine and zofran for symptom management. He
also received lasix 40mg IV x 1 because of evidence of heart
failure on exam.

MEDICAL HISTORY: CAD s/p MI ([**2175**]) and multiple overlapping DES to LCx ([**2176-8-5**])

MEDICATION ON ADMISSION: CURRENT MEDICATIONS: (x = confirmed with pharmacy: [**Telephone/Fax (1) 15113**])

ALLERGIES: Neurontin / Prozac

PHYSICAL EXAM: VS: T 97.4, BP 90/48, HR 71, RR 16, O2 94% on 5L
Gen: Overweight gentleman in significant distress from pain and
anxiety. Oriented x3. Anxious. Somewhat circuitous with answers.

FAMILY HISTORY: There is a family history of premature coronary artery disease
in his grandmother and aunt.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use: he has smoked [**1-15**] PPD x "all my life". There is a
history of alcohol abuse in the past; he has been sober x 8
years. He admits to using 4 lines of cocaine 2 days ago.
Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Cocaine abuse, unspecified
Subendo infarct, initial,Ac on chr syst hrt fail,Comp-oth cardiac device,Crnry athrscl natve vssl,Chrnc hpt C wo hpat coma,DMII wo cmp nt st uncntr,Hypertension NOS,Esophageal reflux,Cocaine abuse-unspec
Admission Date:  [**2177-7-26**]              Discharge Date:   [**2177-8-1**]

Date of Birth:  [**2124-4-21**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Neurontin / Prozac

Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
[**7-26**] Cardiac Catheterization
[**7-28**] Off-Pump Coronary Artery Bypass Graft x 3 (LIMa to LAD, SVG
to Ramus, SVG to OM)

History of Present Illness:
53yo gentleman with h/o CAD (2 vessel disease of LCx and
co-dominant RCA), mild systolic CHF (EF 45%), and DM2
transferred from [**Hospital3 417**] with NSTEMI.
Patient reports stuttering exertional and non-exertional chest
pain for anywhere from days to months, depending on the
interviewer. He had dismissed the pain as being due to acid
reflux. Of note, he had stopped taking many of his cardiac
medications (including plavix, metoprolol, lisinopril, and
imdur) without discussing the matter with his PCP. [**Name10 (NameIs) **] finally
came into the hospital at [**Hospital3 **] because his pain did not go
away after a few days despite taking antacids. He also admits to
doing 4 lines of cocaine 2 days prior to presentation. During
his initial work-up at [**Hospital1 **], he was found to have ST
depressions in V5 and V6 with troponin of 3.1, at which point he
was transferred to [**Hospital1 18**]. He received ASA, plavix 300mg, and
lovenox and was on a nitro gtt prior to transfer. He was also on
an amiodarone gtt for reported frequent ectopy.
In the ED, his initial VS were: 97.2 146/85 25 95% 4L. He was
having mild chest pain and frequent runs of NSVT. Cardiology was
consulted for positive biomarkers. He was put on an integrillin
gtt and given morphine and zofran for symptom management. He
also received lasix 40mg IV x 1 because of evidence of heart
failure on exam.

Past Medical History:
CAD s/p MI ([**2175**]) and multiple overlapping DES to LCx ([**2176-8-5**])

HTN
Hyperlipidemia--no LDL, HDL available at [**Hospital1 18**]
GERD
DM2--no A1C available
Nocturia
Hepatitis C--no viral load available
Chronic back pain s/p laminectomies, rod placement d/t
injury--on chronic methadone
COPD--no PFTs available
Arthritis
Bipolar

Social History:
Social history is significant for the presence of current
tobacco use: he has smoked [**1-15**] PPD x "all my life". There is a
history of alcohol abuse in the past; he has been sober x 8
years. He admits to using 4 lines of cocaine 2 days ago.

Family History:
There is a family history of premature coronary artery disease
in his grandmother and aunt.

Physical Exam:
VS: T 97.4, BP 90/48, HR 71, RR 16, O2 94% on 5L
Gen: Overweight gentleman in significant distress from pain and
anxiety. Oriented x3. Anxious. Somewhat circuitous with answers.

HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8-10cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Somewhat distant heart sounds, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. ? crackles at bases
b/l, though patient has difficulty staying still for exam
secondary to pain. No wheeze.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. Femoral sheath in place with IABP.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+; Femoral sheath in place; DP dopplerable
Left: Carotid 2+; Femoral 1+ without bruit; 2+ DP

Pertinent Results:
EKG (06:39) demonstrated NSR with normal axis and good R wave
progression. T wave flattening in aVL and III that is old as
compared with prior dated [**2176-8-16**].
EKG (08:28) as above with frequent PVCs.
EKG (16:19) NSR with normal axis and T wave flattening in aVL,
III, ? ST depressions in V4 and V5.
QTc in all EKGs is prolonged, ranging up to 477ms.

[**7-26**] Cardiac Cath: 1.  Selective coronary angiography of this
co-dominant system revealed three vessel coronary artery
disease.  The LMCA had mild disease.  The LAD had a 60-70%
proximal tubular lesion.  The LCX was subtotally occluded with
diffuse in stent restenosis and thrombosis.  The RCA was
distally occluded and filled by collaterals. 2.  Limited resting
hemodynamics revealed significantly elevated left sided filling
pressures with LVEDP of 45 mm Hg.  There was no gradient upon
pullback of the catheter from LV to the aorta.  There was mild
systemic arterial hypotension of 94/65 mm Hg. 3.  Left
ventriculography was deferred. 4.  Successful insertion of IABP.

[**7-28**] Echo: PREGrafting: No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. There is moderate to severe regional left ventricular
systolic dysfunction with dyskinesis of the inferolateral wall,
hypokinesis of the distal anterior and anterolateral walls..
LVEF ~25-30%. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
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. The MR
increased to (2+) moderate during manipulation of the heart
during off pump CABG. A well positioned balloon pump catheter is
seen in the descending thoracic aorta. Post Grafting: 1+ mitral
regurgitation seen post-grafting. Aortic balloon pump catheter
remains in descending thoracic aorta just distal to the
subclavian artery. LV function and wall motion appears mildly
improved. (EF 30-35%.) The distal anterior wall appears to be
improved. Previous wall motion abnormalities persist. Remaining
exam is unchanged from pre-grafting.

[**2177-7-26**] 06:50AM BLOOD WBC-11.7*# RBC-4.04*# Hgb-12.5* Hct-36.4*
MCV-90# MCH-30.9# MCHC-34.2 RDW-13.8 Plt Ct-248
[**2177-7-31**] 05:11AM BLOOD WBC-9.6 RBC-2.98* Hgb-9.3* Hct-27.9*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.3 Plt Ct-176
[**2177-7-26**] 06:50AM BLOOD PT-12.7 PTT-34.1 INR(PT)-1.1
[**2177-7-30**] 02:10AM BLOOD PT-13.4 PTT-30.4 INR(PT)-1.1
[**2177-7-26**] 06:50AM BLOOD Glucose-266* UreaN-29* Creat-0.9 Na-134
K-6.2* Cl-98 HCO3-28 AnGap-14
[**2177-7-31**] 05:11AM BLOOD Glucose-179* UreaN-40* Creat-1.1 Na-130*
K-5.1 Cl-96 HCO3-33* AnGap-6*
[**2177-8-1**] 05:00PM BLOOD WBC-8.3 RBC-3.24* Hgb-10.0* Hct-29.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-14.3 Plt Ct-268#
    [**Known lastname **],[**Known firstname 7167**] [**Medical Record Number 15111**] M  53  [**2124-4-21**]

Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2177-7-30**] 4:45 PM


[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2177-7-30**] SCHED
CHEST PORT. LINE PLACEMENT   Clip # [**Clip Number (Radiology) 15112**]
Reason: assess for line position, pneumothorax



[**Hospital 93**] MEDICAL CONDITION:
   53 year old man s/p RIJ central line exchange over wire
REASON FOR THIS EXAMINATION:
   assess for line position, pneumothorax



Wet Read: KYg WED [**2177-7-30**] 5:46 PM
RIJ SWAN GANZ EXCHANGED FOR CVL. NO PTX. SCATTERED ATELECTASIS
SLIGHTLY
IMPROVED IN THE LEFT BASE. MILDLY IMPROVED. PULMONARY VASCULAR
CONGESTION.
CARDIOMEGALY UNCHNANGED. [**Doctor Last Name 7410**]


Final Report
HISTORY: Right IJ central line exchange over wire, to assess for
position.

FINDINGS: In comparison with the study of [**7-29**], the right IJ
Swan-Ganz
catheter tip lies in the lower portion of the SVC. Continued
enlargement of
the cardiac silhouette with improving atelectatic changes at the
left base.
Some evidence of pulmonary vascular congestion and continued
cardiomegaly.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**Doctor First Name **] [**2177-7-31**] 1:44 PM




Brief Hospital Course:
53yo gentleman with h/o CAD s/p DES in [**7-/2176**], DM, and recent
cocaine abuse admitted with NSTEMI and acute on chronic systolic
heart failure, also noted to have frequent bursts of NSVT. When
his cardiac enzymes trended up (CD 1452->1463 with positive MB
fraction), it was decided to take him to the cath lab. In the
cath lab, he was found to have a subtotally occluded LCx with
diffuse in-stent restenosis. The RCA was occluded distally but
filled by collaterals. His LAD had 60-70% proximal disease. It
was felt that treating the LCx lesions in the cath lab might
compromise his collateral circulation and he was referred to CT
surgery for evaluation. Hemodynamics revealed LV EDP of 45 and
an IABP was placed. On [**7-28**] he was brought to the operating room
where he underwent a off-pump coronary artery bypass graft x 3.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later on op day he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one his IABP was removed. Beta-blockers and diuretics were
initiated on this day and he was gently diuresed towards his
pre-op weight. On post-op day two he was transferred to the
telemetry floor for further care.Pain services,substance
abuse,psychiatry and social work were all consulted for
reccommendations. Dilaudid PCA dc'd and converted to oral
agents.On POD#4 Mr.[**Known lastname 4020**] was ready for discharge.
Follow up as outpatient for institution of ACE-I, unable to
start prior to discharge due to BP.

Medications on Admission:
CURRENT MEDICATIONS: (x = confirmed with pharmacy: [**Telephone/Fax (1) 15113**])

ASA 325mg daily
xPlavix 75mg daily
xNTG SL 0.3mg Q5min PRN
Insulin Glargine 50-60units [**Hospital1 **]/Lispro 20 units Q supper
xOxycodone 15mg QID
xMethadone 50mg TID
xValium 5mg TID
Omeprazole 20mg daily
Calcium Carbonate 1500mg [**Hospital1 **]
xAlbuterol 2 puffs QID
xAmbien 5mg QHS PRN
xDocusate 100mg [**Hospital1 **]
xMiralax powder 1 capsule daily
Psyllium [**Hospital1 **]

Of note, patient was on metoprolol 12.5 [**Hospital1 **], lisinopril 5, imdur
30, lasix 10, tamsulosin 0.4, rosiglitazone 4, and cymbalta 60,
all of which he stopped b/c of concern for side effects but did
not tell his PCP he had done so.

Discharge Medications:
1. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day): please continue as prior to admission and follow up with
PCP .
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: please continue as prior to admission
and follow up with your PCP .
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
10. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Solution Sig: 50  units
Subcutaneous twice a day.
Disp:*qs qs* Refills:*2*
13. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please resume home dosing .
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
17. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Coronary Artery Disease s/p Off-Pump Coronary Artery Bypass
Graft x 3
Myocardial Infarction
Acute on chronic systolic heart failure
PMH: s/p Multiple DES to LCX, Hypertension, Hyperlipidemia,
Hepatitis C, Diabetes Mellitus, Gastroesophageal Reflux Disease,
Anxiety, Bipolar Disease, Chronic Pain (on Methadone)

Discharge Condition:
Good

Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Do not use lotions, powders, or creams on wounds.
Call our office for temp.>101.5, sternal drainage.
Shower daily, let water flow over wounds, pat dry with a towel.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Please avoid all use of cocaine or illicit drugs as they will
interfer with your recovery and medications.

Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) **] in [**1-15**] weeks
Follow up with  outpt.substance abuse counsellor


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

Completed by:[**2177-8-1**]
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Cocaine abuse, unspecified'}


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: 53yo gentleman with h/o CAD (2 vessel disease of LCx and
co-dominant RCA), mild systolic CHF (EF 45%), and DM2
transferred from [**Hospital3 417**] with NSTEMI.
Patient reports stuttering exertional and non-exertional chest
pain for anywhere from days to months, depending on the
interviewer. He had dismissed the pain as being due to acid
reflux. Of note, he had stopped taking many of his cardiac
medications (including plavix, metoprolol, lisinopril, and
imdur) without discussing the matter with his PCP. [**Name10 (NameIs) **] finally
came into the hospital at [**Hospital3 **] because his pain did not go
away after a few days despite taking antacids. He also admits to
doing 4 lines of cocaine 2 days prior to presentation. During
his initial work-up at [**Hospital1 **], he was found to have ST
depressions in V5 and V6 with troponin of 3.1, at which point he
was transferred to [**Hospital1 18**]. He received ASA, plavix 300mg, and
lovenox and was on a nitro gtt prior to transfer. He was also on
an amiodarone gtt for reported frequent ectopy.
In the ED, his initial VS were: 97.2 146/85 25 95% 4L. He was
having mild chest pain and frequent runs of NSVT. Cardiology was
consulted for positive biomarkers. He was put on an integrillin
gtt and given morphine and zofran for symptom management. He
also received lasix 40mg IV x 1 because of evidence of heart
failure on exam.

MEDICAL HISTORY: CAD s/p MI ([**2175**]) and multiple overlapping DES to LCx ([**2176-8-5**])

MEDICATION ON ADMISSION: CURRENT MEDICATIONS: (x = confirmed with pharmacy: [**Telephone/Fax (1) 15113**])

ALLERGIES: Neurontin / Prozac

PHYSICAL EXAM: VS: T 97.4, BP 90/48, HR 71, RR 16, O2 94% on 5L
Gen: Overweight gentleman in significant distress from pain and
anxiety. Oriented x3. Anxious. Somewhat circuitous with answers.

FAMILY HISTORY: There is a family history of premature coronary artery disease
in his grandmother and aunt.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use: he has smoked [**1-15**] PPD x "all my life". There is a
history of alcohol abuse in the past; he has been sober x 8
years. He admits to using 4 lines of cocaine 2 days ago. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute on chronic systolic heart failure,Other complications due to other cardiac device, implant, and graft,Coronary atherosclerosis of native coronary artery,Chronic hepatitis C without mention of hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Esophageal reflux,Cocaine abuse, unspecified'}
