CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: Pt is 55 yo f with chronic constipation, who presented to [**Hospital 26580**]
Hospital on [**5-18**] with sudden onset epigastric pain radiating to
back and chest. Pt also had nausea at that time. She had CTA
chest which was negative for PE. She was ruled out for MI. She
had an elevated Alk Phos, LDH, ALT, and AST, and underwent an
abdominal CT which showed duct dilation of 13mm. Pt also had
MRCP, which showed duct size up to 16mm with nonobstructing
multiple common bile duct stones. Pt underwent ERCP
w/sphincterotomy last PM, and upon returning to the floor had
new [**11-13**] sub-sternal chest pressure (also felt in her back).
She was given pain medications, and started on a nitro gtt. Trop
I rose to 2.2. CT reportedly was done and ruled out PE. She says
the pain has been constant since last PM. She was transferred to
[**Hospital1 18**] for further evaluate of her chest pain early this morning.

MEDICAL HISTORY: 1)neuropathy s/p MVA
2)s/p lap chole in [**2150**]
3)s/p abdominal hysterectomy
4)chronic constipation
5)rectocele
6)s/p knee and back surgery
7)s/p colon polypectomy
8)s/p breast biopsy
9)tubal sterilization
10)cholecystitis s/p recent ERCP [**5-21**]

MEDICATION ON ADMISSION: Lyrica 50mg [**Hospital1 **]
MVI
morphine sulfate 30mg [**Hospital1 **] prn
Levsin (Hyoscyamine) 0.125mg [**Hospital1 **]

ALLERGIES: Penicillins / Ciprofloxacin

PHYSICAL EXAM: VS: T 98.0 BP 143/85 HR 72 RR 16 O2 99% 2L
Gen: WDWN middle aged female, initially agitated and thrashing
around in pain. Appeared more comfortable with pain medications.
Oriented x1-2.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father died of MI at age 57. Mother died from complications of
cardiac cath.

SOCIAL HISTORY: significant for the absence of current tobacco use. There is no
history of alcohol abuse. Lives with husband of 7 years.
Acute pancreatitis,Congenital insufficiency of aortic valve,Aortic valve disorders,Prinzmetal angina,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use
Acute pancreatitis,Cong aorta valv insuffic,Aortic valve disorder,Prinzmetal angina,Hypotension NOS,Drug dermatitis NOS,Adv eff antibiotics NEC
Admission Date:  [**2154-5-22**]              Discharge Date:   [**2154-5-25**]

Date of Birth:  [**2098-9-16**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Ciprofloxacin

Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Cardiac catheterization ([**2154-5-22**])


History of Present Illness:

Pt is 55 yo f with chronic constipation, who presented to [**Hospital 26580**]
Hospital on [**5-18**] with sudden onset epigastric pain radiating to
back and chest. Pt also had nausea at that time. She had CTA
chest which was negative for PE. She was ruled out for MI. She
had an elevated Alk Phos, LDH, ALT, and AST, and underwent an
abdominal CT which showed duct dilation of 13mm. Pt also had
MRCP, which showed duct size up to 16mm with nonobstructing
multiple common bile duct stones. Pt underwent ERCP
w/sphincterotomy last PM, and upon returning to the floor had
new [**11-13**] sub-sternal chest pressure (also felt in her back).
She was given pain medications, and started on a nitro gtt. Trop
I rose to 2.2. CT reportedly was done and ruled out PE. She says
the pain has been constant since last PM. She was transferred to
[**Hospital1 18**] for further evaluate of her chest pain early this morning.

.
Upon arrival to the floor pt had SBP in 100's, however she then
had SBP in 80's. Nitro gtt was turned off, and pt was given
500cc NS bolus. SBP increased to 100's. She initially denied
CP/SOB, however shortly after nitro gtt was turned off, pt c/o
[**8-13**] crushing sub-sternal CP. A stat echo was performed which
showed anteroseptal WMA. Her cardiac enzymes returned postive;
she was started on IV heparin given ASA 325mg and Plavix 600mg
x1, and then taken to the cath lab. On initial visualization of
her coronaries, no coronary abnormality was noted, but a focal
anterobasal dyskinetic focal area. After repeated CP in the
holding area, review of the cath films showed a possible kink in
the diagonal branch. She was taken back to the cath lab which
showed a widely patent diagonal with no significant stenosis,
but again demonstrated the focal wall motion abnormality.
.
On arrival to the CCU, patient still c/o of [**11-13**] abd pain, but
denied any chest pain, shortness of breath, difficulty
breathing, pruritis, nausea or vomiting. She denied any
palpitations. She was given 1mg of Ativan, 1 mg of dilaudid and
her pain decreased.


Past Medical History:

1)neuropathy s/p MVA
2)s/p lap chole in [**2150**]
3)s/p abdominal hysterectomy
4)chronic constipation
5)rectocele
6)s/p knee and back surgery
7)s/p colon polypectomy
8)s/p breast biopsy
9)tubal sterilization
10)cholecystitis s/p recent ERCP [**5-21**]


Social History:
significant for the absence of current tobacco use. There is no
history of alcohol abuse. Lives with husband of 7 years.

Family History:
Father died of MI at age 57. Mother died from complications of
cardiac cath.

Physical Exam:

VS: T 98.0 BP 143/85 HR 72 RR 16 O2 99% 2L
Gen: WDWN middle aged female, initially agitated and thrashing
around in pain. Appeared more comfortable with pain medications.
Oriented x1-2.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

Neck: Supple.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly.
Abd: Soft, nd, +BS. Epigastric region and periumbilical region
mildly tender to palpation, no rebound or involuntary guarding.
No HSM. Abd aorta not enlarged by palpation. No abdominial
bruits. R groin with bandaged groin.
Ext: No c/c/e. No femoral bruits.
Skin: Mildly diffuse maculopapular rash across trunk and back.
.


Pertinent Results:
Cardiac Cath [**2154-5-22**]:
1. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent flow-limiting coronary artery disease.
 There
was one view that suggested a focal kink in the proximal
diagonal artery
that would match the focal anterobasal wall motion abnormality.
However, on repeat views, the diagonal artery appeared widely
patent.
Possibilities for her myocardial abnormalities include coronary
vasospasm, intermittent kinking of the diagonal vessel,
intermittent
small thrombus, and focal myocarditis.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 23 mmHg.  Systemic arterial pressure
was
high-normal with a BP of 139/84 mmHg.  There was no transaortic
valve
gradient on pullback of the catheter from the LV to the aorta.
3. Left ventriculography demonstrated no mitral regurgitation.
The
calculated LVEF was 56% with a focal anterobasal dyskinetic
region.
.
Thin Barium Swallow:
IMPRESSION: No evidence of esophageal rupture on this limited
study. Patient could not stand upright and mobility was limited
for oblique views. Optimal luminal distention was not
established. Study had to be terminated early due to new onset
arrythmias.
.
TTE [**5-24**]:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is low normal (LVEF 50%) secondary
to focal hypokinesis of the midventricular segment of the
anterior free wall and lateral wall. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is moderately dilated athe
sinus level. The ascending aorta is mildly dilated. The aortic
arch is mildly dilated. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened.
There is mild aortic valve stenosis (area 1.2-1.9cm2). Mild (1+)
aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2154-5-22**], the overall ejection fraction is increased due
to less extensive hypokinesis of the anterior free wall. A
bicuspid aortic valve is now recognized (mild aortic stenosis).

.
CT abd/pelvis [**5-24**]:
1. Status post ERCP, with biliary stent in place. Mild
pneumobilia is expected post-ERCP finding. Mildly dilated common
bile duct.
2. Normally enhancing pancreas, without evidence of
peripancreatic fat stranding, fluid collection or pseudocyst.
3. Two noncalcified 4-mm pulmonary nodules. In the absence of
any known malignancy or risk factors such as smoking, no
followup is necessary. If there are known risk factors, a
12-month followup chest CT is recommended.

Brief Hospital Course:
55 yo f with fam hx of CAD, who presented with crushing SSCP s/p
ERCP with new anteroseptal WMA with normal coronary anatomy and
possible kinked Diagonal vessel.
.
1. CAD:
No previous history of CAD with episode of SSCP s/p ERCP. Now
with new anteroseptal WMA, normal EKG but biomarkers c/w NSTEMI,
and normal cath without evidence of coronary disease or
thrombosis except for possible kinked diagonal vessel.  This
likely represented a stress related cardiomyopathy (similar to
Takatsubo's) that may resolve on repeat TTE in several weeks
time.  Given the lack of CAD seen on cardiac cath, no change in
her medication regimen was made at this time.  Pt was discharged
to follow up with her PCP as needed.

2. [**Name (NI) **]
Pt with a mildly diminshed EF of 50% with a new anterobasal
hypokinetic area which is thought to correlate with her stress
related NSTEMI.  This may resolve with time, and patient was
advised to have a repeat TTE in [**4-7**] weeks' time after discharge.
 An appointment was requested to follow up our cardiologist, Dr.
[**Last Name (STitle) **] in 8 weeks time to follow up on resolution of this
WMA.
.
3. Valves
A new bicuspid aortic valve was found during this admission with
a mild aortic valve stenosis.  She was advised to use antibiotic
prophylaxsis during dental procedures (given scrip for
azithromycin given her ? PCN allergy).
.
4. Choledocholithiasis s/p ERCP c/b mild pancreatitis:
She was transferred to [**Hospital1 18**] after her ERCP with sphincterotomy
and biliary stent placement. Apparent difficult procedure likely
led to post-ERCP mild pancreatitis (lipase 125 -> 87 --> 27) as
well as abdominal pain from sphincter manipulation. Epigastric
pain likely all due to manipulation of sphincter as this
resolved completely during her hospitalization.  A follow up CT
abd/pelvis was obtained during this admission which showed
resolution of CBD dilatation and no residual stones.
Ciprofloxacin was continue for post-ERCP ppx although this had
to be discontinued due to a possible allergy leading a diffuse
maculopapular rash.  She was advised to follow up with the
physician who performed the ERCP to have her biliary stent
removed in 4 weeks time.  Pt was pain free and tolerating
regular diet at time of discharge.
.
5. Chronic Pain:
She was continued on her chronic MS contin 30 [**Hospital1 **] and lyrica for
her chronic pain.  She was to follow up with her PCP regarding
further issues.
.
DISPO: She is to follow up with her PCP as well as her GI
physician to have her biliary stent removed in 4 weeks time.
Please follow up with Dr. [**Last Name (STitle) **] from cardiology in 8 weeks
time (after obtaining a follow up TTE).

Medications on Admission:

Lyrica 50mg [**Hospital1 **]
MVI
morphine sulfate 30mg [**Hospital1 **] prn
Levsin (Hyoscyamine) 0.125mg [**Hospital1 **]


Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual [**Hospital1 **] (2 times a day).
2. Benadryl 25 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for itching.
Disp:*30 Tablet(s)* Refills:*0*
3. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical TID:PRN as needed for itching.
Disp:*1 large tube* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Lyrica 150 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once as
needed for antibiotic prophylaxis prior to dental procedure:
Take 1 hour prior to dental procedure.
Disp:*5 Tablet(s)* Refills:*0*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once as needed for chest pain: Take 1 tablet every 5
minutes as needed for chest pain, maximum 3 tablets.
Disp:*30 tablets* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Post ERCP pancreatitis
Hypotension, resolved
Probable coronary artery vasospasm
Bicuspid aortic valve with mild aortic stenosis


Discharge Condition:
Stable condition, normotensive, eating full diet.


Discharge Instructions:
We believe that you probably had spasm of one of your coronary
arteries, resulting in chest pain and slightly depressed heart
function. We believe that this will improve over time, and
recommend a repeat echocardiogram in [**7-12**] weeks to assess
interval change.

While in the hospital, you were given a medication called
Ciprofloxacin following placement of a biliary stent. You
subsequently developed a rash, and we believe that Ciprofloxacin
may have been the culprit. We have added this medication to your
list of allergies. It may take several weeks for the rash to
resolve.

Please note that you were also found to have a bicuspid aortic
valve (2 leaflets instead of 3). Because of this condition, we
recommend that you take antibiotic prophylaxis prior to any
dental procedure to prevent infection of the heart valve. We
have prescribed Azithromycin, 500 mg by mouth 1 hour before
procedure. You should also talk to your doctor prior to any
other procedure to see if you need antibiotics.

Please return to the ED or call your PCP if you develop fever or
chills, worsening abdominal pain, or chest pain or shortness of
breath.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (cardiology) in [**7-12**] weeks.
Please call his office at ([**Telephone/Fax (1) 5862**].

Please follow-up at [**Hospital3 3583**] with the physician that
performed your ERCP. You will need the biliary stent removed in
several weeks.

Please follow-up with your primary care doctor, Dr. [**First Name (STitle) 5656**], this
week to discuss your hospital admission.

Previously scheduled appointments:
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-7-30**] 10:10

Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2154-7-30**] 10:30



Completed by:[**2154-5-25**]
{'Acute pancreatitis,Congenital insufficiency of aortic valve,Aortic valve disorders,Prinzmetal angina,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic 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: Pt is 55 yo f with chronic constipation, who presented to [**Hospital 26580**]
Hospital on [**5-18**] with sudden onset epigastric pain radiating to
back and chest. Pt also had nausea at that time. She had CTA
chest which was negative for PE. She was ruled out for MI. She
had an elevated Alk Phos, LDH, ALT, and AST, and underwent an
abdominal CT which showed duct dilation of 13mm. Pt also had
MRCP, which showed duct size up to 16mm with nonobstructing
multiple common bile duct stones. Pt underwent ERCP
w/sphincterotomy last PM, and upon returning to the floor had
new [**11-13**] sub-sternal chest pressure (also felt in her back).
She was given pain medications, and started on a nitro gtt. Trop
I rose to 2.2. CT reportedly was done and ruled out PE. She says
the pain has been constant since last PM. She was transferred to
[**Hospital1 18**] for further evaluate of her chest pain early this morning.

MEDICAL HISTORY: 1)neuropathy s/p MVA
2)s/p lap chole in [**2150**]
3)s/p abdominal hysterectomy
4)chronic constipation
5)rectocele
6)s/p knee and back surgery
7)s/p colon polypectomy
8)s/p breast biopsy
9)tubal sterilization
10)cholecystitis s/p recent ERCP [**5-21**]

MEDICATION ON ADMISSION: Lyrica 50mg [**Hospital1 **]
MVI
morphine sulfate 30mg [**Hospital1 **] prn
Levsin (Hyoscyamine) 0.125mg [**Hospital1 **]

ALLERGIES: Penicillins / Ciprofloxacin

PHYSICAL EXAM: VS: T 98.0 BP 143/85 HR 72 RR 16 O2 99% 2L
Gen: WDWN middle aged female, initially agitated and thrashing
around in pain. Appeared more comfortable with pain medications.
Oriented x1-2.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Father died of MI at age 57. Mother died from complications of
cardiac cath.

SOCIAL HISTORY: significant for the absence of current tobacco use. There is no
history of alcohol abuse. Lives with husband of 7 years. 

### Response:
{'Acute pancreatitis,Congenital insufficiency of aortic valve,Aortic valve disorders,Prinzmetal angina,Hypotension, unspecified,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use'}
