CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 76 yo female who underwent a cardiac catheterization in [**Month (only) 404**]
[**2114**] (atherectomy and cypher stent to proximal LAD). She was
discharged on aspirin and plavix. However the patient has
refractory anemia with excess blasts in transformation to acute
myelogenous leukemia (last chemotherapy was last week, diagnosed
in [**Month (only) 596**]), PLT 31, and plavix and aspirin was stopped under the
direction of her oncologist and cardiologist. Yesterday patient
presented to [**Hospital1 1806**] ER with c/o CP at rest,radiating to her
right shoulder and in to her back, worsening throughout the day.
EKG showed inferior lead ischemia, Trop peaked at 3.58. Has been
having intermittent chest pain since this AM, [**9-3**] in
intensity, was given 2 slnitro's, 1mg Morphine x's 2, dilaudid
w/relief of the pain. This AM EKG showed ST elevation in
inferior leads.
.
On route to [**Hospital1 18**], the patient was experiencing nausea and
vomiting. On arrival to the floor, EKG showed juncional rhythm
at 50, with 1-3mm ST elevation in II, III, avF with reciprocal
changes in anterior leads. No aspirin or heparin given due to
pt's low platelets. She was given morphine with some relief of
pain. After speaking to pt's oncologist, Dr. [**Name (NI) **], pt was given
baby aspirin. Overnight, the patient's creatinine bumped to 3.1
from 1 and she was oliguric. She was transferred to the CCU for
a temporary pacer as it was thought that increasing her heart
rate and subsequently her cardiac output, she would have greater
perfusion to her kidneys and increased UOP. Before placing the
pacer, she was tried on Dopamine which did result in a higher HR
and increased UOP but caused 10/10 chest pain. Once in the CCU
and assessed by EP, it was decided that she would not have a
pacer placed at that time.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. Left total hip replacement
4. Left Nephrectomy [**12-27**] kidney stones 20 years ago
5. Partial hysterectomy.
6. Renital disease (detached retina which led to workup of blood
problems)
7. MDS with blasts in transformation to AML
8. CAD: [**2114-12-5**]: ROTA and Cypher stent to pLAD
9. s/p hysterectomy

MEDICATION ON ADMISSION: Meds at home:
Lopressor 100mg Daily
Danazol 50mg QID
Predisone 5mg daily
.
Meds on transfer: Lopressor 100mg [**Hospital1 **], Prednisone 5mg daily,
Lisinopril 5mg daily, Zocor 40mg daily, Nitro paste [**11-26**]"

ALLERGIES: Sulfa (Sulfonamides) / Shellfish

PHYSICAL EXAM: VS: BP 100/50  HR 50  RR 16 98% 2L
Gen: having chest pain, resting in bed, partly relieved by
morphine
HEENT: R pupil minimally reactive, L pupil reacts.  OP clear
Neck: + JVD, no LAD
Lungs: CLAB
Heart: bradycardic, S1S2, no murmur, rub, gallop
Abd: +BS, soft, ND/NT
Extrem: no edema

FAMILY HISTORY: CAD: brother died of MI in 60's, sister died 59y/o heart dz, son

SOCIAL HISTORY: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children.
Acute myocardial infarction of other inferior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Atrial fibrillation,Acute myeloid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Acquired absence of kidney,Hip joint replacement,Cyst of kidney, acquired,Anemia in neoplastic disease
AMI inferior wall, init,Ac kidny fail, tubr necr,Hyperpotassemia,Atrial fibrillation,Ac myl leuk wo achv rmsn,Thrombocytopenia NOS,Crnry athrscl natve vssl,Hypertension NOS,Pure hypercholesterolem,Acquired absence kidney,Joint replaced hip,Cyst of kidney, acquired,Anemia in neoplastic dis
Admission Date:  [**2115-8-6**]              Discharge Date:   [**2115-8-14**]

Date of Birth:  [**2039-4-9**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides) / Shellfish

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Placement of temporary cardiac pacemaker and removal.


History of Present Illness:
76 yo female who underwent a cardiac catheterization in [**Month (only) 404**]
[**2114**] (atherectomy and cypher stent to proximal LAD). She was
discharged on aspirin and plavix. However the patient has
refractory anemia with excess blasts in transformation to acute
myelogenous leukemia (last chemotherapy was last week, diagnosed
in [**Month (only) 596**]), PLT 31, and plavix and aspirin was stopped under the
direction of her oncologist and cardiologist. Yesterday patient
presented to [**Hospital1 1806**] ER with c/o CP at rest,radiating to her
right shoulder and in to her back, worsening throughout the day.
EKG showed inferior lead ischemia, Trop peaked at 3.58. Has been
having intermittent chest pain since this AM, [**9-3**] in
intensity, was given 2 slnitro's, 1mg Morphine x's 2, dilaudid
w/relief of the pain. This AM EKG showed ST elevation in
inferior leads.
.
On route to [**Hospital1 18**], the patient was experiencing nausea and
vomiting. On arrival to the floor, EKG showed juncional rhythm
at 50, with 1-3mm ST elevation in II, III, avF with reciprocal
changes in anterior leads. No aspirin or heparin given due to
pt's low platelets. She was given morphine with some relief of
pain. After speaking to pt's oncologist, Dr. [**Name (NI) **], pt was given
baby aspirin. Overnight, the patient's creatinine bumped to 3.1
from 1 and she was oliguric. She was transferred to the CCU for
a temporary pacer as it was thought that increasing her heart
rate and subsequently her cardiac output, she would have greater
perfusion to her kidneys and increased UOP. Before placing the
pacer, she was tried on Dopamine which did result in a higher HR
and increased UOP but caused 10/10 chest pain. Once in the CCU
and assessed by EP, it was decided that she would not have a
pacer placed at that time.


Past Medical History:
1. HTN
2. Hypercholesterolemia
3. Left total hip replacement
4. Left Nephrectomy [**12-27**] kidney stones 20 years ago
5. Partial hysterectomy.
6. Renital disease (detached retina which led to workup of blood
problems)
7. MDS with blasts in transformation to AML
8. CAD: [**2114-12-5**]: ROTA and Cypher stent to pLAD
9. s/p hysterectomy

Social History:
She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children.


Family History:
CAD: brother died of MI in 60's, sister died 59y/o heart dz, son

MI at 49y/o. sister with [**Name2 (NI) 500**] CA
M died of uterine CA
F died of stroke, +HTN.

Physical Exam:
VS: BP 100/50  HR 50  RR 16 98% 2L
Gen: having chest pain, resting in bed, partly relieved by
morphine
HEENT: R pupil minimally reactive, L pupil reacts.  OP clear
Neck: + JVD, no LAD
Lungs: CLAB
Heart: bradycardic, S1S2, no murmur, rub, gallop
Abd: +BS, soft, ND/NT
Extrem: no edema

Pertinent Results:
OSH Labs: Wbc 4.4 Hgb 9.8 Hct 29.9 (transfused last week at
[**Location (un) **]) Plt 31; Na 139; K+ 4.5; CL 109; CO2 26; BUN 24; creat
1.1; Trop 3.58 (up from 1.54)
.
EKG: Junctional rhythm at 50, ST elevation in II, III, aVF, with
reciprocal changes in anterior leads

Brief Hospital Course:
A/P: 76 F with MDS in transformation to AML, thrombocytopenia
who presented to [**Hospital1 18**] with inferior STEMI. The following issues
were investigated during this hospitalization:
.
# Cardiac:
a) CAD/Inferior STEMI: The patient was not a candidate for
reperfusion as she has hematologic abnormalities (low platelets)
and could not have long term anti-platelet therapy with aspirin
or plavix. She also could not get heparin due to bleeding risk.
She received supportive care with ASA, statin, a beta blocker
and Morphine for pain. An ace-inhibitor was not given initially
because of acute renal failure, but the was added once the ARF
resolved.
.
b) Rhythm: Initially, patient had a junctional rhythm that was
stable. However, she later experienced recurrent asystolic
pauses up to 6 seconds. For this reason, a temporary screw-in
pacer was placed with settings of VVI at a rate of 60. The
patient was found to only intermittently require her pacer and
was in normal sinus rhythm. The pacer was gradually decreased
from 60 to 50 to 40 and the patient continued to pace as high as
in the 70s on her own. As a result, the pacemaker was d/c'd on
[**8-13**]. The patient was discharged in normal sinus rhythm.
.
c) Pump: EF of 50% with inferior hypokinesis and RV dysfunction
on echo on [**8-8**]. Given the RV involvement, the aim for her fluid
status was even to positive as it was important to support her
preload. This was done without incident.
.
# Hematology/Oncology: Patient is followed by Dr. [**First Name (STitle) **] for MDS
with blasts in transformation to AML. She had been receiving
chemo until the week prior to her admission. Oncology was made
aware that the patient had been admitted and followed her during
her hospitalization. Chemotherapy was held while the patient was
treated for an acute MI. A follow-up appointment was made with
oncology after discharge.
.
# Acute Renal Failure: Thought to be due to ATN as a result of
poor perfusion. There was marked concern as the patient only has
one kidney. The patient had little to no urine output after
first being admitted, but during her hospitalization, her
creatinine trended down and her urinary ouput increased.
Nephrology was following te patient but eventually signed off as
the ARF resolved and there was no need for HD. Patient's
electrolytes were monitored and corrected without incident.
.
#Renal cysts: Patient was found to have a new nodular component
to renal cysts on u/s with recommendation to have an MRI to
further evaluate these cysts. Pt. to pursue an MRI as an
outpatient.
.

# Code: DNR/DNI


Medications on Admission:
Meds at home:
Lopressor 100mg Daily
Danazol 50mg QID
Predisone 5mg daily
.
Meds on transfer: Lopressor 100mg [**Hospital1 **], Prednisone 5mg daily,
Lisinopril 5mg daily, Zocor 40mg daily, Nitro paste [**11-26**]"

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*10 Tablet(s)* Refills:*0*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO qd PRN as
needed for swollen feet.
Disp:*5 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*


Discharge Disposition:
Home with Service

Discharge Diagnosis:
Inferior STEMI
Junctional Rhythm
Bradycardia
AML
Neutropenia


Discharge Condition:
Heart rate in the 60-70's sinus rhythm, afebrile, appropriate
followup arranged.


Discharge Instructions:

1. Please take all medications as directed.  Please note that we
have changed your blood pressure medications, and added daily
aspirin and liptor.
2. Please keep all appointments.
3. Call your doctor or go to the ER for any of the following:
chest pain, shortness of breath, fever >100.4, chills or any
other concerning symptoms.

Followup Instructions:
Hematolgy/Oncology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**First Name (Titles) **] [**Last Name (Titles) 8848**],[**First Name3 (LF) **] C
Phone:[**Telephone/Fax (1) 3237**] Date/Time: [**2115-8-23**] 3:30

Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2115-10-24**] 3:20
{'Acute myocardial infarction of other inferior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Atrial fibrillation,Acute myeloid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Acquired absence of kidney,Hip joint replacement,Cyst of kidney, acquired,Anemia in neoplastic disease'}


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: 76 yo female who underwent a cardiac catheterization in [**Month (only) 404**]
[**2114**] (atherectomy and cypher stent to proximal LAD). She was
discharged on aspirin and plavix. However the patient has
refractory anemia with excess blasts in transformation to acute
myelogenous leukemia (last chemotherapy was last week, diagnosed
in [**Month (only) 596**]), PLT 31, and plavix and aspirin was stopped under the
direction of her oncologist and cardiologist. Yesterday patient
presented to [**Hospital1 1806**] ER with c/o CP at rest,radiating to her
right shoulder and in to her back, worsening throughout the day.
EKG showed inferior lead ischemia, Trop peaked at 3.58. Has been
having intermittent chest pain since this AM, [**9-3**] in
intensity, was given 2 slnitro's, 1mg Morphine x's 2, dilaudid
w/relief of the pain. This AM EKG showed ST elevation in
inferior leads.
.
On route to [**Hospital1 18**], the patient was experiencing nausea and
vomiting. On arrival to the floor, EKG showed juncional rhythm
at 50, with 1-3mm ST elevation in II, III, avF with reciprocal
changes in anterior leads. No aspirin or heparin given due to
pt's low platelets. She was given morphine with some relief of
pain. After speaking to pt's oncologist, Dr. [**Name (NI) **], pt was given
baby aspirin. Overnight, the patient's creatinine bumped to 3.1
from 1 and she was oliguric. She was transferred to the CCU for
a temporary pacer as it was thought that increasing her heart
rate and subsequently her cardiac output, she would have greater
perfusion to her kidneys and increased UOP. Before placing the
pacer, she was tried on Dopamine which did result in a higher HR
and increased UOP but caused 10/10 chest pain. Once in the CCU
and assessed by EP, it was decided that she would not have a
pacer placed at that time.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. Left total hip replacement
4. Left Nephrectomy [**12-27**] kidney stones 20 years ago
5. Partial hysterectomy.
6. Renital disease (detached retina which led to workup of blood
problems)
7. MDS with blasts in transformation to AML
8. CAD: [**2114-12-5**]: ROTA and Cypher stent to pLAD
9. s/p hysterectomy

MEDICATION ON ADMISSION: Meds at home:
Lopressor 100mg Daily
Danazol 50mg QID
Predisone 5mg daily
.
Meds on transfer: Lopressor 100mg [**Hospital1 **], Prednisone 5mg daily,
Lisinopril 5mg daily, Zocor 40mg daily, Nitro paste [**11-26**]"

ALLERGIES: Sulfa (Sulfonamides) / Shellfish

PHYSICAL EXAM: VS: BP 100/50  HR 50  RR 16 98% 2L
Gen: having chest pain, resting in bed, partly relieved by
morphine
HEENT: R pupil minimally reactive, L pupil reacts.  OP clear
Neck: + JVD, no LAD
Lungs: CLAB
Heart: bradycardic, S1S2, no murmur, rub, gallop
Abd: +BS, soft, ND/NT
Extrem: no edema

FAMILY HISTORY: CAD: brother died of MI in 60's, sister died 59y/o heart dz, son

SOCIAL HISTORY: She is a widow and lives alone in [**Hospital1 1806**], Mass. She does have a
20 pack-year smoking history but quit 7 years ago. She denies
alcohol use. She has two children. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Acute kidney failure with lesion of tubular necrosis,Hyperpotassemia,Atrial fibrillation,Acute myeloid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia,Acquired absence of kidney,Hip joint replacement,Cyst of kidney, acquired,Anemia in neoplastic disease'}
