CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: 86 year old woman has a history of hypertension, hyperlipidemia,
atrial fibrillation on Coumadin and breast cancers/p lumpectomy.
She reports a long history of chest discomfort that she always
dismissed in the past. Recently it has been occurring with
increasing frequency. It occurs more often with exertion but has
also occurred at rest. She describes it as a sharp pain in the
mid chest that radiates to the back. Recent stress testing was
positive for symptoms and EKG changes but perfusion imaging was
negative. She was referred for left heart catheterization. She
was found to have Left main disease and is emergently going to
OR for CABG with Dr. [**Last Name (STitle) **].

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Atrial fibrillation on Coumadin
[**6-/2147**]: Invasive ductal left breast cancer s/p lumpectomy
Glaucoma
Osteoarthritis
Appendectomy
Pernicious anemia
Right jaw surgery -"lock jaw"
Constipation
Osteoporosis

MEDICATION ON ADMISSION: ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth
weekly
BIMATOPROST [LUMIGAN] - 0.03 % Drops - 1 drop eye at bedtime
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually daily PRN You may take up to three tabets
five minutes apart. If the pain does not resolve, call 911.
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
TIMOLOL [BETIMOL] -  (Prescribed by Other Provider) - 0.5 %
Drops - 1 drop ou every evening
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily Dosage
adjusted by INR
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1000 mg by mouth three
times a day PRN
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth 1 as needed for daily
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - 500 mg-200 unit-[**Unit Number **] mcg
Tablet, Chewable - 1 Tablet(s) by mouth three times a day

ALLERGIES: Penicillins / Chicken Derived / [**Country **]

PHYSICAL EXAM: Pulse:62 Resp:12  O2 sat:98/RA
B/P  Right:155/60   Left:156/66
Height:5'1"    Weight:145  lbs

FAMILY HISTORY: Premature coronary artery disease- non contributory

SOCIAL HISTORY: Race:Caucasian
Last Dental Exam:upper dentures, several missing teeth with poor
repair
Lives with:niece, Ambulates with a cane
Contact: [**Name (NI) 11923**] [**Name (NI) 6632**] (great niece):[**0-0-**]
Coronary atherosclerosis of native coronary artery,Pernicious anemia,Intermediate coronary syndrome,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Osteoporosis, unspecified,Family history of ischemic heart disease,Personal history of tobacco use
Crnry athrscl natve vssl,Pernicious anemia,Intermed coronary synd,Hypertension NOS,Hyperlipidemia NEC/NOS,Atrial fibrillation,Long-term use anticoagul,Hx of breast malignancy,Glaucoma NOS,Osteoarthros NOS-unspec,Constipation NOS,Osteoporosis NOS,Fam hx-ischem heart dis,History of tobacco use
Admission Date:  [**2147-12-25**]              Discharge Date:   [**2147-12-29**]

Date of Birth:  [**2061-11-16**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / Chicken Derived / [**Country **]

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain

Major Surgical or Invasive Procedure:
[**2147-12-25**] Coronary artery bypass grafting x2 with a left internal
mammary artery to left anterior descending artery and reverse
saphenous vein graft to the ramus intermedius artery

History of Present Illness:
86 year old woman has a history of hypertension, hyperlipidemia,
atrial fibrillation on Coumadin and breast cancers/p lumpectomy.
She reports a long history of chest discomfort that she always
dismissed in the past. Recently it has been occurring with
increasing frequency. It occurs more often with exertion but has
also occurred at rest. She describes it as a sharp pain in the
mid chest that radiates to the back. Recent stress testing was
positive for symptoms and EKG changes but perfusion imaging was
negative. She was referred for left heart catheterization. She
was found to have Left main disease and is emergently going to
OR for CABG with Dr. [**Last Name (STitle) **].

Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation on Coumadin
[**6-/2147**]: Invasive ductal left breast cancer s/p lumpectomy
Glaucoma
Osteoarthritis
Appendectomy
Pernicious anemia
Right jaw surgery -"lock jaw"
Constipation
Osteoporosis

Social History:
Race:Caucasian
Last Dental Exam:upper dentures, several missing teeth with poor
repair
Lives with:niece, Ambulates with a cane
Contact: [**Name (NI) 11923**] [**Name (NI) 6632**] (great niece):[**0-0-**]

Occupation:retired
Cigarettes: Smoked no [] yes [x]Hx:  2.5 packs a day for 25
years, quit 30 years ago
Other Tobacco use:
ETOH: < 1 drink/week [x]  [**2-27**] drinks/week [] >8 drinks/week []
Illicit drug use

Family History:
Premature coronary artery disease- non contributory

Physical Exam:
Pulse:62 Resp:12  O2 sat:98/RA
B/P  Right:155/60   Left:156/66
Height:5'1"    Weight:145  lbs

General:
Skin: Dry [x] intact [x] skin tag left neck
HEENT: PERRLA [x] EOMI [x] injected right sclera
Neck:  Supple [x] Full ROM []x
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular [x]  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema - none
Varicosities: None [x] superficial veins bilateral shins
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: sheath in place   Left: 2+
DP           Right: 1+  Left: 1+
PT           [**Name (NI) 167**]: 1+  Left: 1+
Radial       Right: 2+  Left: 2+

Carotid Bruit        Right: none    Left: none

Pertinent Results:
Admission Labs:
[**2147-12-25**] 10:03AM   PT-11.7 PTT-28.4 INR(PT)-1.1
[**2147-12-25**] 10:03AM   PLT COUNT-177
[**2147-12-25**] 10:03AM   WBC-6.1 RBC-4.28 HGB-12.9 HCT-38.0 MCV-89
MCH-30.0 MCHC-33.8 RDW-12.5
[**2147-12-25**] 10:03AM   GLUCOSE-84 UREA N-14 CREAT-1.1 SODIUM-140
POTASSIUM-6.6* CHLORIDE-105 TOTAL CO2-25 ANION GAP-17
Discharge Labs:

[**2147-12-29**] 05:30AM BLOOD WBC-9.9 RBC-3.06* Hgb-9.0* Hct-27.3*
MCV-89 MCH-29.4 MCHC-33.0 RDW-12.7 Plt Ct-150
[**2147-12-29**] 05:30AM BLOOD Plt Ct-150
[**2147-12-29**] 05:30AM BLOOD PT-21.5* INR(PT)-2.0*
[**2147-12-29**] 05:30AM BLOOD Glucose-79 UreaN-27* Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-30 AnGap-10
[**2147-12-28**] 06:10AM BLOOD Mg-2.4

[**2147-12-25**] Cath: 1. Coronary angiography in this right dominant
system demonstrated significant left main disease. The LMCA had
an 80% distal stenosis. The LAD had a mid 40% stenosis. The LCX
had no angiographically apparent disease. The RCA had a mid 40%
stenosis. 2. Limited resting hemodynamics revealed elevated
systemic arterial pressures at the central aortic level 162/61
mmHG. 3. Left Ventriculography was deferred.

[**2147-12-25**] Echo: PRE-BYPASS: No spontaneous echo contrast is seen
in the body of the left atrium. Mild spontaneous echo contrast
is present in the left atrial appendage. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with mild
hypokinesis of the distal anterolateral wall as well as the
anterior wall and apex, The right ventricle displays normal free
wall contractility. The ascending aorta is mildly dilated. There
is a small fibrinous echodensity in the left ventricular outflow
tract 1 cm below the right coronary cusp. There are simple
atheroma in the aortic arch. The descending thoracic aorta is
mildly dilated. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of
the results in the operating room at the time of the study.
POST BYPASS There is noemal biventricular systolic function.
Valvular function is unchanged. The thoracic aorta is intact
after decannulation. No other significant changes from the
pre-bypass exam.

Radiology Report CHEST (PA & LAT) Study Date of [**2147-12-29**] 11:47
AM
Final Report: In comparison with the study of [**12-26**], there are
again bilateral pleural effusions best seen on the lateral
projection. No evidence of vascular congestion or acute
pneumonia. Right IJ catheter has been removed.



Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname **] underwent a cardiac cath
on [**12-25**] which demonstrated severe left main disease. Cardiac
surgery was consulted and she was emergently taken to the
operating room and underwent a coronary artery bypass graft x 2.
Please see operative report for surgical details. In summary she
had CABG x2 with: left internal mammary artery to left anterior
descending artery and reverse saphenous vein graft to obtuse
marginal artery. her bypass time was 42 minutes and crossclamp
time was 31 minutes. She tolerated the operation well and
following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Later this day she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was started on beta-blockers and diuretics
and gently diuresed towards her pre-op weight. On post-op day
two her chest tubes were removed and she was transferred to the
step-down unit for further recovery. Post-op she was in atrial
fibrillation (has a history of chronic atrial fibrillation) and
Coumadin was started. Once on the stepdown floor her hospital
course was uneventful. She worked with the nursing and physical
therapy staff to increase strength and endurance, her progress
was slow. On post-op day three epicardial pacing wires were
removed.
On POD4 she was cleared for transfer to rehabilitation at either
[**Hospital 100**] Rehab [**Hospital1 8**] on the [**Doctor Last Name **] whichever the family
chooses.

Medications on Admission:
ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth
weekly
BIMATOPROST [LUMIGAN] - 0.03 % Drops - 1 drop eye at bedtime
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually daily PRN You may take up to three tabets
five minutes apart. If the pain does not resolve, call 911.
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
TIMOLOL [BETIMOL] -  (Prescribed by Other Provider) - 0.5 %
Drops - 1 drop ou every evening
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily Dosage
adjusted by INR
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1000 mg by mouth three
times a day PRN
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth 1 as needed for daily
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - 500 mg-200 unit-[**Unit Number **] mcg
Tablet, Chewable - 1 Tablet(s) by mouth three times a day

Discharge Medications:
1. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. mupirocin calcium 2 % Ointment Sig: One (1) Appl Nasal [**Hospital1 **] (2
times a day) for 5 days: stop [**12-30**].
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: target INR 2-2.5.
11. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 2 weeks.
14. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: [**12-29**] dose.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 2
Past medical history:
Hypertension
Hyperlipidemia
Atrial fibrillation on Coumadin
[**6-/2147**]: Invasive ductal left breast cancer s/p lumpectomy
Glaucoma
Osteoarthritis
Appendectomy
Pernicious anemia
Right jaw surgery -"lock jaw"
Constipation
Osteoporosis

Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right EVH- healing well, no erythema or drainage.
Edema: 1+ bilat


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 approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
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:
Surgeon: Dr. [**Last Name (STitle) **] on [**2148-2-1**] @1PM [**Telephone/Fax (1) 1504**] [**Hospital Unit Name **]
[**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2148-3-20**] 10:20

Primary Care: [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2148-3-18**] 9:30

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

Labs: PT/INR for Coumadin ?????? indication -Atrial Fibrillation
Goal INR 2-2.5
First draw [**12-30**]



Completed by:[**2147-12-29**]
{'Coronary atherosclerosis of native coronary artery,Pernicious anemia,Intermediate coronary syndrome,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Osteoporosis, unspecified,Family history of ischemic heart disease,Personal history of tobacco use'}


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: 86 year old woman has a history of hypertension, hyperlipidemia,
atrial fibrillation on Coumadin and breast cancers/p lumpectomy.
She reports a long history of chest discomfort that she always
dismissed in the past. Recently it has been occurring with
increasing frequency. It occurs more often with exertion but has
also occurred at rest. She describes it as a sharp pain in the
mid chest that radiates to the back. Recent stress testing was
positive for symptoms and EKG changes but perfusion imaging was
negative. She was referred for left heart catheterization. She
was found to have Left main disease and is emergently going to
OR for CABG with Dr. [**Last Name (STitle) **].

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Atrial fibrillation on Coumadin
[**6-/2147**]: Invasive ductal left breast cancer s/p lumpectomy
Glaucoma
Osteoarthritis
Appendectomy
Pernicious anemia
Right jaw surgery -"lock jaw"
Constipation
Osteoporosis

MEDICATION ON ADMISSION: ALENDRONATE [FOSAMAX] - 70 mg Tablet - 1 Tablet(s) by mouth
weekly
BIMATOPROST [LUMIGAN] - 0.03 % Drops - 1 drop eye at bedtime
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
NITROGLYCERIN [NITROSTAT] - 0.3 mg Tablet, Sublingual - 1
Tablet(s) sublingually daily PRN You may take up to three tabets
five minutes apart. If the pain does not resolve, call 911.
SIMVASTATIN - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime
TIMOLOL [BETIMOL] -  (Prescribed by Other Provider) - 0.5 %
Drops - 1 drop ou every evening
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily Dosage
adjusted by INR
ACETAMINOPHEN [TYLENOL] - 325 mg Tablet - 1000 mg by mouth three
times a day PRN
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth 1 as needed for daily
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - 500 mg-200 unit-[**Unit Number **] mcg
Tablet, Chewable - 1 Tablet(s) by mouth three times a day

ALLERGIES: Penicillins / Chicken Derived / [**Country **]

PHYSICAL EXAM: Pulse:62 Resp:12  O2 sat:98/RA
B/P  Right:155/60   Left:156/66
Height:5'1"    Weight:145  lbs

FAMILY HISTORY: Premature coronary artery disease- non contributory

SOCIAL HISTORY: Race:Caucasian
Last Dental Exam:upper dentures, several missing teeth with poor
repair
Lives with:niece, Ambulates with a cane
Contact: [**Name (NI) 11923**] [**Name (NI) 6632**] (great niece):[**0-0-**] 

### Response:
{'Coronary atherosclerosis of native coronary artery,Pernicious anemia,Intermediate coronary syndrome,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Atrial fibrillation,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast,Unspecified glaucoma,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Constipation, unspecified,Osteoporosis, unspecified,Family history of ischemic heart disease,Personal history of tobacco use'}
