CHIEF COMPLAINT: Chest pain and increasing DOE.

PRESENT ILLNESS: 77 yo woman w/ h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN,
dyslipidemia presents with chest pain and SOB x2 days, off and
on. Also feeling "exhaustion" with minimal exertion. Sharp-type
pain, substernal in location, burning and traveling up to her
throat. Similar to her anginal type pain. She says the pain has
been coming and going intermittently during the last two days,
sometimes occurring at rest. Typically her pain is relieved with
nitroglycerin.
.
She presented to [**Hospital **] Hospital night of [**8-20**] because the pain
had worsened and was not resolving with 3 SL nitro and an ASA.
Her VS were T 98.4, HR 86, BP 118/63, RR 18, satting 96% RA. On
exam she had clear breath sounds with normal cardiac exam. Labs
were remarkable for hct 27, chem 7 notable for creatinine 1.2;
LFTs were normal. CK was 49 with CKMB-I of 5.3. TropI was 0.07,
repeat 0.14. Her EKG showed ST depressions in the lateral leads
(I, aVL, and V4-V6). There was ST elevation in lead aVR. She was
admitted to the ICU at OSH and started on heparin gtt, nitro
gtt, Integrillin gtt, mucomyst and continued on amlodipine 10
mg, ASA 81 mg, Plavix 75 mg, Lasix 20 mg PO, metoprolol 50 mg
TID, and simvastatin 80 mg qday. She was also started on 2units
of blood for Hct <30 in setting of ischemia. She was then
transferred to [**Hospital1 18**] for management.
.
She was transferred directly from OSH to CCU. At time of arrival
to CCU, she is CP free. Denies palpitations, lightheadedness, or
dizziness.
.
Of note, she presented to [**Hospital1 18**] with an NSTEMI in [**2157-4-24**]
and underwent catheterization with BMS placed to a 90% stenotic
but protected LM. The overlap segment was postdilated to 3.5mm.
Final angiography revealed 0% residual stenosis, no
angiographically apparent dissection and timi3 flow. The patient
left the lab free of angina and in stable condition. She says
that after this procedure she was CP free for several weeks, but
believes that her anginal symptoms have worsened progressively
since.
.
At baseline, says she can walk one flight of stairs before
becoming SOB. Endorses lower extremity edema; sleeps on one
pillow at night; denies orthopnea, paroxysmal nocturnal dyspnea.
No new cough. No fevers. No melena or hematochezia. She has a
history of anemia, says that "she is bleeding internally, but
[**Last Name (un) 15025**] knows where." No fevers, chills, night sweats, weight loss
of which she is aware.

MEDICAL HISTORY: # (+) Diabetes, (+) Dyslipidemia, (+) Hypertension
# Coronary Artery Disease s/p CABG x 4
# HTN
# Peripheral Vascular Disease s/p stenting of her lower leg
# Hyperlipidemia
# Diabetes Mellitus x40 years, insulin dependent
# s/p left tibial fracture 2 years ago
# Hearing Impaired
# Possible COPD vs Asthma - negative w/u for COPD as per
patient.
# Myelodyplastic syndrome - Hct on last hospitalization was mid
30's
# Rotator cuff injury
# Fib-tib fracture [**2154**]

MEDICATION ON ADMISSION: # Lantus 10 U qhs
# Regular insulin with meals
# Norvasc 10 mg qday
# Plavix 75 mg qday
# Isordil 30 mg PO BID
# Potassium 20 meQ qday
# Simvastatin 40 mg qday
# Avapro 150 mg [**Hospital1 **]
# Metoprolol 100 mg PO BID
# Lasix 20 mg qday
# SL NG prn
# ASA 81 mg qday
# Fe Pills - unknown dose
# Procrit qweekly for anemia

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: VS: T97.6, HR 68, BP 153/46, O2 98% 2L NC
GENERAL: elderly woman, hearing impaired, NAD
HEENT: NCAT, pupils constricted, mildly dysconjugate gaze,
NECK: JVD 2-3cm above clavicle at 45 degrees
CARDIAC: RRR, no M/R/G
LUNGS: Bibasilar rales, otherwise clear breath sounds
ABDOMEN: softly distended, no masses, no rebound no guarding.
EXTREMITIES: wwp, L>R non-pitting LE edema,
SKIN: wwp, nevi on back
PULSES: 2+ carotid pulsations, 1+ DP pulses bilaterally,

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Lives with son and two granddaughters. Independent in ADLs and
IADLs. Tobacco history: has not smoked for 16 years. History of
smoking 2PPD x40 years. ETOH: None. Illicit drugs: None
Subendocardial infarction, initial episode of care,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Myelodysplastic syndrome, unspecified,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Old myocardial infarction,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Anemia in neoplastic disease
Subendo infarct, initial,DMII oth nt st uncntrld,Crnry athrscl natve vssl,Status-post ptca,Myelodysplastic synd NOS,Long-term use of insulin,Periph vascular dis NOS,Old myocardial infarct,Hyperlipidemia NEC/NOS,Hypertension NOS,Anemia in neoplastic dis
Admission Date:  [**2157-8-21**]              Discharge Date:   [**2157-8-24**]

Date of Birth:  [**2080-2-12**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain and increasing DOE.

Major Surgical or Invasive Procedure:
Cardiac catheterization


History of Present Illness:
77 yo woman w/ h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN,
dyslipidemia presents with chest pain and SOB x2 days, off and
on. Also feeling "exhaustion" with minimal exertion. Sharp-type
pain, substernal in location, burning and traveling up to her
throat. Similar to her anginal type pain. She says the pain has
been coming and going intermittently during the last two days,
sometimes occurring at rest. Typically her pain is relieved with
nitroglycerin.
.
She presented to [**Hospital **] Hospital night of [**8-20**] because the pain
had worsened and was not resolving with 3 SL nitro and an ASA.
Her VS were T 98.4, HR 86, BP 118/63, RR 18, satting 96% RA. On
exam she had clear breath sounds with normal cardiac exam. Labs
were remarkable for hct 27, chem 7 notable for creatinine 1.2;
LFTs were normal. CK was 49 with CKMB-I of 5.3. TropI was 0.07,
repeat 0.14. Her EKG showed ST depressions in the lateral leads
(I, aVL, and V4-V6). There was ST elevation in lead aVR. She was
admitted to the ICU at OSH and started on heparin gtt, nitro
gtt, Integrillin gtt, mucomyst and continued on amlodipine 10
mg, ASA 81 mg, Plavix 75 mg, Lasix 20 mg PO, metoprolol 50 mg
TID, and simvastatin 80 mg qday. She was also started on 2units
of blood for Hct <30 in setting of ischemia. She was then
transferred to [**Hospital1 18**] for management.
.
She was transferred directly from OSH to CCU. At time of arrival
to CCU, she is CP free. Denies palpitations, lightheadedness, or
dizziness.
.
Of note, she presented to [**Hospital1 18**] with an NSTEMI in [**2157-4-24**]
and underwent catheterization with BMS placed to a 90% stenotic
but protected LM. The overlap segment was postdilated to 3.5mm.
Final angiography revealed 0% residual stenosis, no
angiographically apparent dissection and timi3 flow. The patient
left the lab free of angina and in stable condition. She says
that after this procedure she was CP free for several weeks, but
believes that her anginal symptoms have worsened progressively
since.
.
At baseline, says she can walk one flight of stairs before
becoming SOB. Endorses lower extremity edema; sleeps on one
pillow at night; denies orthopnea, paroxysmal nocturnal dyspnea.
No new cough. No fevers. No melena or hematochezia. She has a
history of anemia, says that "she is bleeding internally, but
[**Last Name (un) 15025**] knows where." No fevers, chills, night sweats, weight loss
of which she is aware.


Past Medical History:
# (+) Diabetes, (+) Dyslipidemia, (+) Hypertension
# Coronary Artery Disease s/p CABG x 4
# HTN
# Peripheral Vascular Disease s/p stenting of her lower leg
# Hyperlipidemia
# Diabetes Mellitus x40 years, insulin dependent
# s/p left tibial fracture 2 years ago
# Hearing Impaired
# Possible COPD vs Asthma - negative w/u for COPD as per
patient.
# Myelodyplastic syndrome - Hct on last hospitalization was mid
30's
# Rotator cuff injury
# Fib-tib fracture [**2154**]


Social History:
Lives with son and two granddaughters. Independent in ADLs and
IADLs. Tobacco history: has not smoked for 16 years. History of
smoking 2PPD x40 years. ETOH: None. Illicit drugs: None


Family History:
There is no family history of premature coronary artery disease
or sudden death.

Physical Exam:
VS: T97.6, HR 68, BP 153/46, O2 98% 2L NC
GENERAL: elderly woman, hearing impaired, NAD
HEENT: NCAT, pupils constricted, mildly dysconjugate gaze,
NECK: JVD 2-3cm above clavicle at 45 degrees
CARDIAC: RRR, no M/R/G
LUNGS: Bibasilar rales, otherwise clear breath sounds
ABDOMEN: softly distended, no masses, no rebound no guarding.
EXTREMITIES: wwp, L>R non-pitting LE edema,
SKIN: wwp, nevi on back
PULSES: 2+ carotid pulsations, 1+ DP pulses bilaterally,


Pertinent Results:
[**2157-8-21**] CK(CPK)-57
[**2157-8-21**] CK-MB-NotDone cTropnT-0.08*
[**2157-8-21**] WBC-4.4# RBC-3.23* HGB-10.7* HCT-30.1* MCV-95 MCH-33.1*
MCHC-34.8 RDW-15.2
[**2157-8-21**] NEUTS-65.7 LYMPHS-20.5 MONOS-9.4 EOS-4.0 BASOS-0.5
[**2157-8-21**] PLT COUNT-202
[**2157-8-21**] PT-14.4* PTT-96.0* INR(PT)-1.3*
[**2157-8-21**] GLUCOSE-205* UREA N-37* CREAT-1.0 SODIUM-136
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-14
[**2157-8-21**] ALT(SGPT)-23 AST(SGOT)-25 LD(LDH)-215 CK(CPK)-56 ALK
PHOS-85 TOT BILI-0.6
[**2157-8-21**] CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2157-8-21**] PT-13.6* PTT-70.6* INR(PT)-1.2*
[**2157-8-21**] CK-MB-NotDone cTropnT-0.05* proBNP-6377*
.
CT Head: No evidence of hemorrhage, edema mass, or recent
infarction. If acute infarct is a consideration, MR [**First Name (Titles) 151**] [**Last Name (Titles) 4639**]n-weighted imaging is the most sensitive modality.
.
ECHO [**2157-8-22**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior hypokinesis. Overall left
ventricular systolic function is normal (LVEF55-60%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

.
CXR [**2157-8-21**]: As compared to the previous radiograph, the
left-sided pleural effusion has almost completely resolved. A
small right-sided pleural effusion has newly occurred. There is
unchanged cardiomegaly with signs of mild overhydration. Focal
parenchymal opacities suggestive of recent pneumonia are not
seen. The sternal wires and clips after bypass surgery are
unchanged.
.
Cardiac Cath (logged only, not official):
LMCA - patent stent
LAD - total occlusion ostial. native fillls via LIMA. Mild
luminal irregularity.
LCx - total occlusion mid vessel. OMI fills via LMCA stent with
mid dx tortous vessel.
SVG - RCA patent with serial 50-60% lesions
LIMA 0 LAD - widely patent


Brief Hospital Course:
77 yo woman h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN,
dyslipidemia presents with chest pain and SOB x 2 days
concerning for unstable angina. EKG shows ST-segment depressions
in the lateral leads concern of stent re-stenosis. Cardiac cath
demonstrates patent LMCA stent.
..
# CORONARIES: Stents patent. Continue CAD prevention. Chest pain
could be secondary to demand ischemia related to anemia.
Consider increasing hematocrit with procrit as outpatient.
Continue CAD prevention: High-dose statin, ASA 325, Plavix 75.
Increased Imdur from 30 mg [**Hospital1 **] to 90 mg qd. Consider increasing
hematocrit using procrit.
.
# PUMP: Mildly elevated JVD, bibasilar rales, and elevated BNP.
No echo in system. CXR demonstrates small right sided effusion.
Gave Lasix 20 mg IV, re-started outpatient Lasix 20 mg po.
.
# RHYTHM: Normal sinus rhythm currently. Continue to monitor on
telemetry.
.
# Hypertension: Poorly controlled, SBP ranged from 137-161.
Re-start outpatient BP meds and was better controlled. Converted
Metoprolol 100 mg [**Hospital1 **] to Toprol 200 mg qd, otherwise continued
outpatient HTN meds.
.
# Anemia: Normocytic, elevated Ferritin, most likely anemia of
chronic disease. Continue outpatient procrit injections
q-weekly, try to increase baseline HCT due to demand ischemia.



Medications on Admission:
# Lantus 10 U qhs
# Regular insulin with meals
# Norvasc 10 mg qday
# Plavix 75 mg qday
# Isordil 30 mg PO BID
# Potassium 20 meQ qday
# Simvastatin 40 mg qday
# Avapro 150 mg [**Hospital1 **]
# Metoprolol 100 mg PO BID
# Lasix 20 mg qday
# SL NG prn
# ASA 81 mg qday
# Fe Pills - unknown dose
# Procrit qweekly for anemia


Discharge Medications:
1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous at bedtime.
11. Insulin Regular Human 100 unit/mL Solution Sig: as directed
as per sliding scale Injection qACHS.


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Hypertension
Anemia [**12-25**] to myelodysplastic syndrome
Diabetes


Discharge Condition:
stable.


Discharge Instructions:
You had some heart strain likely from anemia.  In the hospital
you underwent a cardiac catheterization that showed that the
blood vessels in your heart have adequate blood supply.  You
received a blood transfusion and your medicines were adjusted
because your blood pressure was high.  You were hypoglycemic
(low blood sugar) in the hospital.  Please resume your
outpatient prescriptions as you had previously and discuss
adjusting your regimen with your PCP.  [**Name10 (NameIs) **] the mean time, it
should be safe for you to resume your home insulin regimen if
that has been working for you in the past.  Finally, it is
recommended that in the future you keep a copy of your ECG and
bring it with you to the hospital whenever possible.
.
We made the following changes to your medicines:
1. Isosorbide Mononitrate 90mg daily
2. Toprol XL 200mg daily
3. Regular insulin SS - new scale provided.
.
Please make sure you take your medicines as planned. Please call
Dr. [**Last Name (STitle) 40075**] if you have any symptoms of chest pain, trouble
breathing, increased fatigue, fevers, or dizziness.

Followup Instructions:
Primary Care:
[**Last Name (LF) 40075**], [**Name8 (MD) 333**], MD Phone: [**Telephone/Fax (1) 40076**] Date/Time: [**9-13**] at 1:30pm, [**Hospital 40600**] Medical Building, [**Apartment Address(1) 40601**].
.
Cardiology:
[**Last Name (LF) 8579**], [**First Name3 (LF) 518**] Phone: [**Telephone/Fax (1) 40602**] Date/Time: Monday, [**9-12**] at 11:00am, [**Hospital 40600**] Medical Building, [**Apartment Address(1) 40603**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Completed by:[**2157-8-26**]
{'Subendocardial infarction, initial episode of care,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Myelodysplastic syndrome, unspecified,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Old myocardial infarction,Other and unspecified hyperlipidemia,Unspecified essential hypertension,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 and increasing DOE.

PRESENT ILLNESS: 77 yo woman w/ h/o CAD, s/p CABGx4, PVD s/p stent, DM, HTN,
dyslipidemia presents with chest pain and SOB x2 days, off and
on. Also feeling "exhaustion" with minimal exertion. Sharp-type
pain, substernal in location, burning and traveling up to her
throat. Similar to her anginal type pain. She says the pain has
been coming and going intermittently during the last two days,
sometimes occurring at rest. Typically her pain is relieved with
nitroglycerin.
.
She presented to [**Hospital **] Hospital night of [**8-20**] because the pain
had worsened and was not resolving with 3 SL nitro and an ASA.
Her VS were T 98.4, HR 86, BP 118/63, RR 18, satting 96% RA. On
exam she had clear breath sounds with normal cardiac exam. Labs
were remarkable for hct 27, chem 7 notable for creatinine 1.2;
LFTs were normal. CK was 49 with CKMB-I of 5.3. TropI was 0.07,
repeat 0.14. Her EKG showed ST depressions in the lateral leads
(I, aVL, and V4-V6). There was ST elevation in lead aVR. She was
admitted to the ICU at OSH and started on heparin gtt, nitro
gtt, Integrillin gtt, mucomyst and continued on amlodipine 10
mg, ASA 81 mg, Plavix 75 mg, Lasix 20 mg PO, metoprolol 50 mg
TID, and simvastatin 80 mg qday. She was also started on 2units
of blood for Hct <30 in setting of ischemia. She was then
transferred to [**Hospital1 18**] for management.
.
She was transferred directly from OSH to CCU. At time of arrival
to CCU, she is CP free. Denies palpitations, lightheadedness, or
dizziness.
.
Of note, she presented to [**Hospital1 18**] with an NSTEMI in [**2157-4-24**]
and underwent catheterization with BMS placed to a 90% stenotic
but protected LM. The overlap segment was postdilated to 3.5mm.
Final angiography revealed 0% residual stenosis, no
angiographically apparent dissection and timi3 flow. The patient
left the lab free of angina and in stable condition. She says
that after this procedure she was CP free for several weeks, but
believes that her anginal symptoms have worsened progressively
since.
.
At baseline, says she can walk one flight of stairs before
becoming SOB. Endorses lower extremity edema; sleeps on one
pillow at night; denies orthopnea, paroxysmal nocturnal dyspnea.
No new cough. No fevers. No melena or hematochezia. She has a
history of anemia, says that "she is bleeding internally, but
[**Last Name (un) 15025**] knows where." No fevers, chills, night sweats, weight loss
of which she is aware.

MEDICAL HISTORY: # (+) Diabetes, (+) Dyslipidemia, (+) Hypertension
# Coronary Artery Disease s/p CABG x 4
# HTN
# Peripheral Vascular Disease s/p stenting of her lower leg
# Hyperlipidemia
# Diabetes Mellitus x40 years, insulin dependent
# s/p left tibial fracture 2 years ago
# Hearing Impaired
# Possible COPD vs Asthma - negative w/u for COPD as per
patient.
# Myelodyplastic syndrome - Hct on last hospitalization was mid
30's
# Rotator cuff injury
# Fib-tib fracture [**2154**]

MEDICATION ON ADMISSION: # Lantus 10 U qhs
# Regular insulin with meals
# Norvasc 10 mg qday
# Plavix 75 mg qday
# Isordil 30 mg PO BID
# Potassium 20 meQ qday
# Simvastatin 40 mg qday
# Avapro 150 mg [**Hospital1 **]
# Metoprolol 100 mg PO BID
# Lasix 20 mg qday
# SL NG prn
# ASA 81 mg qday
# Fe Pills - unknown dose
# Procrit qweekly for anemia

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: VS: T97.6, HR 68, BP 153/46, O2 98% 2L NC
GENERAL: elderly woman, hearing impaired, NAD
HEENT: NCAT, pupils constricted, mildly dysconjugate gaze,
NECK: JVD 2-3cm above clavicle at 45 degrees
CARDIAC: RRR, no M/R/G
LUNGS: Bibasilar rales, otherwise clear breath sounds
ABDOMEN: softly distended, no masses, no rebound no guarding.
EXTREMITIES: wwp, L>R non-pitting LE edema,
SKIN: wwp, nevi on back
PULSES: 2+ carotid pulsations, 1+ DP pulses bilaterally,

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Lives with son and two granddaughters. Independent in ADLs and
IADLs. Tobacco history: has not smoked for 16 years. History of
smoking 2PPD x40 years. ETOH: None. Illicit drugs: None 

### Response:
{'Subendocardial infarction, initial episode of care,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Myelodysplastic syndrome, unspecified,Long-term (current) use of insulin,Peripheral vascular disease, unspecified,Old myocardial infarction,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Anemia in neoplastic disease'}
