CHIEF COMPLAINT: s/p left heart catheterization for exertional angina

PRESENT ILLNESS: 64 year old primarily Portuguese speaking woman with diet
controlled diabetes, hypertension and hyperlipidemia has been
experiencing symptoms of angina over the last several months.
Pain is substernal chest discomfort and occurs with exertion and
resolves with rest. She has no pain at rest. Of note, pt
presented to [**Hospital **] hosp ER recently with
nausea/vomiting/headache and was referred for stress testing,
which was done on [**2186-1-3**]. She experienced chest pain during
exercise and EKG was positive for 1-2 mm of upsloping ST segment
depression in V3-V6 and in inferior leads. Nuclear imaging was
normal. She was recommended to get cardiac catheterization after
positive stress result, and she is s/p diagnostic cath today via
right radial access initially, then right groin with 2 puncture
wounds, which "demonstrated left main and 2 vessel coronary
artery disease. The LMCA had an 80% ostial stenosis. The LAD had
a 60% lesion in the mid-aspect of the vessel. The LCx had minor
luminal irregularities. The RCA was notable for a proximal 70%
stenosis that was long, as well as a 50% mid lesion." She was
then admitted for for CABG and cardiac surgery is following. She
has been placed on a heparin gtt but has not been given plavix.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: AMLODIPINE 5 mg daily
HYDROCHLOROTHIAZIDE 25 mg Daily
LISINOPRIL 40 mg daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual- 1 Tablet sub lingually
PRN
OMEPRAZOLE 20 mg Daily
PRAVASTATIN 40 mg Daily
RANITIDINE HCL 300 mg Daily- Last dose two months ago
ASPIRIN 81 mg Daily

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM:
VS: 98.4, 138/65, 60, 16, 99% 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.
NECK: no JVD.
CARDIAC: RRR, [**3-21**] scratchy-sounding systolic murmur heard best
at USB's. no gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi at lateral bases or anteriorly; could not
assess posteriorly due to pt requiring supine position
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

FAMILY HISTORY: sister has a pacemaker at age 61, father had "open heart
surgery".

SOCIAL HISTORY: widow. lives with daughter. On disability.
Tobacco: no
ETOH: no
Illicits: no
Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Other and unspecified hyperlipidemia,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia, unspecified,Thrombocytopenia, unspecified
Crnry athrscl natve vssl,Intermed coronary synd,Hyperlipidemia NEC/NOS,Esophageal reflux,DMII wo cmp nt st uncntr,Hypertension NOS,Anemia NOS,Thrombocytopenia NOS
Admission Date:  [**2186-2-21**]              Discharge Date:   [**2186-2-27**]

Date of Birth:  [**2121-4-21**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
s/p left heart catheterization for exertional angina

Major Surgical or Invasive Procedure:
[**2186-2-23**]
Coronary artery bypass grafting x3 with left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch of the right coronary artery.


History of Present Illness:
64 year old primarily Portuguese speaking woman with diet
controlled diabetes, hypertension and hyperlipidemia has been
experiencing symptoms of angina over the last several months.
Pain is substernal chest discomfort and occurs with exertion and
resolves with rest. She has no pain at rest. Of note, pt
presented to [**Hospital **] hosp ER recently with
nausea/vomiting/headache and was referred for stress testing,
which was done on [**2186-1-3**]. She experienced chest pain during
exercise and EKG was positive for 1-2 mm of upsloping ST segment
depression in V3-V6 and in inferior leads. Nuclear imaging was
normal. She was recommended to get cardiac catheterization after
positive stress result, and she is s/p diagnostic cath today via
right radial access initially, then right groin with 2 puncture
wounds, which "demonstrated left main and 2 vessel coronary
artery disease. The LMCA had an 80% ostial stenosis. The LAD had
a 60% lesion in the mid-aspect of the vessel. The LCx had minor
luminal irregularities. The RCA was notable for a proximal 70%
stenosis that was long, as well as a 50% mid lesion." She was
then admitted for for CABG and cardiac surgery is following. She
has been placed on a heparin gtt but has not been given plavix.

.
She denies prior history of cardiac disease. She denies
shortness of breath while lying on her back and shortness of
breath in general. She sleeps on three pillows at night [**2-16**]
reflux. No nausea, vomiting, headache. No change in BM or blood
in stool. No swelling in hands or feet. Admits to leg cramping
in her right leg.
.
On arrival to the floor, patient was lying comfortably on her
back. She denies CP, admits only to pain in right wrist and in
her back, which is chronic. Vitals on arrival to floor are 98.4,
138/65, 60, 16, 99% RA.
.
REVIEW OF SYSTEMS
per HPI

Past Medical History:
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:
diabetes- diet controlled
hypertension
hyperlipdemia
appendectomy
knee surgery- metal implant
GERD


Social History:
widow. lives with daughter. On disability.
Tobacco: no
ETOH: no
Illicits: no


Family History:
sister has a pacemaker at age 61, father had "open heart
surgery".

Physical Exam:
ADMISSION EXAM:
VS: 98.4, 138/65, 60, 16, 99% 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.
NECK: no JVD.
CARDIAC: RRR, [**3-21**] scratchy-sounding systolic murmur heard best
at USB's. no gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi at lateral bases or anteriorly; could not
assess posteriorly due to pt requiring supine position
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ DP's bilat, 2+ radial on left, could not assess right
radial [**2-16**] post-cath sheath

Discharge
 99.0   81 SR   100/59   18   92%-RA
Gen NAD
Neuro A&O x3, nonfocal
CV RRR, no murmur. Sternum stable incision CDI
Pulm CTA-bilat
Abdm soft, NT/ND/+BS
Ext warm trace LE edema

Pertinent Results:
ADMISSION LABS:
[**2186-2-21**] 10:15AM BLOOD WBC-7.3 RBC-3.73* Hgb-11.4* Hct-31.2*
MCV-84 MCH-30.5 MCHC-36.5* RDW-13.3 Plt Ct-160
[**2186-2-21**] 10:15AM BLOOD Neuts-68.0 Lymphs-26.3 Monos-4.4 Eos-0.6
Baso-0.7
[**2186-2-21**] 10:15AM BLOOD PT-12.6* PTT-150* INR(PT)-1.2*
[**2186-2-21**] 10:15AM BLOOD Glucose-114* UreaN-17 Creat-0.9 Na-142
K-4.0 Cl-105 HCO3-25 AnGap-16
[**2186-2-21**] 10:15AM BLOOD ALT-15 AST-23 AlkPhos-67 TotBili-0.6
[**2186-2-22**] 06:50AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.9
[**2186-2-21**] 10:15AM BLOOD Albumin-3.8
[**2186-2-21**] 10:15AM BLOOD %HbA1c-6.5* eAG-140*
Discharge labs:
[**2186-2-27**] 05:15AM BLOOD WBC-9.7 RBC-3.70* Hgb-11.1* Hct-32.2*
MCV-87 MCH-30.1 MCHC-34.5 RDW-13.8 Plt Ct-177#
[**2186-2-27**] 05:15AM BLOOD Plt Ct-177#
[**2186-2-25**] 04:29AM BLOOD PT-13.7* PTT-31.0 INR(PT)-1.3*
[**2186-2-27**] 05:15AM BLOOD UreaN-19 Creat-0.9 Na-135 K-4.5 Cl-98

IMAGING:
C. CATH [**2186-2-21**]: 1. Selective coronary angiography of this right
dominant system demonstrated left main and 2 vessel coronary
artery disease.  The LMCA had an 80% ostial stenosis.  The LAD
had a 60% lesion in the mid-aspect of the vessel.  The LCx had
minor luminal irregularities.  The RCA was notable for a
proximal 70% stenosis that was long, as well as a 50% mid
lesion. 2. Limited resting hemodynamics revealed normal systemic
systolic arterial pressures, with a central aortic pressure of
138/66, mean 97 mmHg.
FINAL DIAGNOSIS:
1. Left main and two vessel coronary artery disease.
2. Systemic systolic arterial normotension.
3. Evaluation for coronary artery bypass graft surgery.

CAROTID DUPLEX:Minimal bilateral ICA calcific plaque, no
appreciable associated stenosis, however, (graded as less than
40% bilaterally).

Radiology Report CHEST (PA & LAT) Study Date of [**2186-2-27**] 3:59 PM

FINDINGS: As compared to the previous radiograph, the patient
has developed mild bilateral pleural effusions, better visible
than on the previous radiograph and better seen on the lateral
than on the frontal image. The size of the cardiac silhouette is
unchanged. There are mild areas of basal atelectasis but no
evidence of acute changes. The right central venous access line
has been removed in the interval.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  0.8 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.8 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  4.5 cm  <= 5.6 cm
Left Ventricle - Ejection Fraction:  50% to 55%  >= 55%
[**Hospital1 **] - Ascending:  3.4 cm  <= 3.4 cm
Aortic Valve - Peak Gradient:  6 mm Hg  < 20 mm Hg
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
[**Hospital1 **]: Normal ascending [**Hospital1 5236**] diameter. Simple atheroma in
descending [**Hospital1 5236**].
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications.
Conclusions
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic [**Hospital1 5236**].
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
There is no pericardial effusion.
Post-CPB:
The patient is on no inotropes and is AV-Paced.
Preserved biventricular systolic fxn.
Trace TR, no AI, no MR.
[**First Name (Titles) **] [**Last Name (Titles) 5235**].
  Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician

Brief Hospital Course:
64 year old female with HTN, HLD, and DM found to have two
vessel disease with left main on cardiac catheterization and
referred to cardiac surgery for evascularization.
After preop workup patient was brought to the operating room for
Coronary bypass grafting with Dr [**Last Name (STitle) **] on [**2186-2-23**]. Please see
the operative report for details, in summary she had:
Coronary artery bypass grafting x3 with left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch of the right coronary artery. her
bypass time was 61 minutes with a crossclamp time of 48 minutes.
She tolerated the operation well and post-operatively was
transferred to the cardiac surgery ICU in stable condition. In
the immediate post-op period she remained hemodynamically
stable, woke neurologically [**Date Range 5235**] and was extubated. She
remained stable throughout the operative night and on POD1 she
was started on Bblockers and diuretics. Additionally she was
transferred to the stepdown floor for continued post-operative
management. All tubes lines and drains were removed per cardiac
surgery protocol.
Once on the floor she worked with nursing and physical therapy
to increase her strength and mobility. The remainder of her
hospital course was uneventful. On POD4 she was cleared for
discharge home with visiting nurses. She is to follow up with Dr
[**Last Name (STitle) **] in 1 month

Medications on Admission:
AMLODIPINE 5 mg daily
HYDROCHLOROTHIAZIDE 25 mg Daily
LISINOPRIL 40 mg daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual- 1 Tablet sub lingually
PRN
OMEPRAZOLE 20 mg Daily
PRAVASTATIN 40 mg Daily
RANITIDINE HCL 300 mg Daily- Last dose two months ago
ASPIRIN 81 mg Daily


Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm PO DAILY (Daily).


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
coronary artery disease s/p CABG x3
PMHx: diabetes- diet controlled hypertension hyperlipidemia GERD
Lumbosacral Neuritis appendectomy s/p repair of Left lateral
meniscus tear [**2174-1-13**]


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema- trace bilat LE


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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:
[**Hospital 409**] Clinic [**2186-3-7**] @ 10:45AM [**Telephone/Fax (1) 1504**]
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] [**2186-3-29**] @1PM [**Telephone/Fax (1) 1504**]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2186-3-30**] 1:40

Primary Care Dr.[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2186-4-17**] 12:15

Provider: [**First Name8 (NamePattern2) 2206**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2186-4-21**] 2:00

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



Completed by:[**2186-2-27**]
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Other and unspecified hyperlipidemia,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia, unspecified,Thrombocytopenia, 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: s/p left heart catheterization for exertional angina

PRESENT ILLNESS: 64 year old primarily Portuguese speaking woman with diet
controlled diabetes, hypertension and hyperlipidemia has been
experiencing symptoms of angina over the last several months.
Pain is substernal chest discomfort and occurs with exertion and
resolves with rest. She has no pain at rest. Of note, pt
presented to [**Hospital **] hosp ER recently with
nausea/vomiting/headache and was referred for stress testing,
which was done on [**2186-1-3**]. She experienced chest pain during
exercise and EKG was positive for 1-2 mm of upsloping ST segment
depression in V3-V6 and in inferior leads. Nuclear imaging was
normal. She was recommended to get cardiac catheterization after
positive stress result, and she is s/p diagnostic cath today via
right radial access initially, then right groin with 2 puncture
wounds, which "demonstrated left main and 2 vessel coronary
artery disease. The LMCA had an 80% ostial stenosis. The LAD had
a 60% lesion in the mid-aspect of the vessel. The LCx had minor
luminal irregularities. The RCA was notable for a proximal 70%
stenosis that was long, as well as a 50% mid lesion." She was
then admitted for for CABG and cardiac surgery is following. She
has been placed on a heparin gtt but has not been given plavix.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: AMLODIPINE 5 mg daily
HYDROCHLOROTHIAZIDE 25 mg Daily
LISINOPRIL 40 mg daily
NITROGLYCERIN 0.4 mg Tablet, Sublingual- 1 Tablet sub lingually
PRN
OMEPRAZOLE 20 mg Daily
PRAVASTATIN 40 mg Daily
RANITIDINE HCL 300 mg Daily- Last dose two months ago
ASPIRIN 81 mg Daily

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION EXAM:
VS: 98.4, 138/65, 60, 16, 99% 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.
NECK: no JVD.
CARDIAC: RRR, [**3-21**] scratchy-sounding systolic murmur heard best
at USB's. no gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi at lateral bases or anteriorly; could not
assess posteriorly due to pt requiring supine position
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.

FAMILY HISTORY: sister has a pacemaker at age 61, father had "open heart
surgery".

SOCIAL HISTORY: widow. lives with daughter. On disability.
Tobacco: no
ETOH: no
Illicits: no 

### Response:
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Other and unspecified hyperlipidemia,Esophageal reflux,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia, unspecified,Thrombocytopenia, unspecified'}
