CHIEF COMPLAINT: Exertional Angina

PRESENT ILLNESS: History is obtained from the medical record and from the patient
with her son serving as interpreter. Please see also OMR notes
by Dr. [**Last Name (STitle) **] from [**2133-8-13**] and Dr. [**Name (NI) **] from [**2133-6-12**] for
additional information. Briefly, Ms. [**Known lastname 21557**] is a 80 year old
Persian woman who has multiple medical problems including
diet-controlled type II diabetes, hypertension, chronic joint
pain (osteoarthritis and seronegative RA vs. PMR), and recent
visual problems with ocular discomfort. She has had recent
complaints of chest pain and progressive dyspnea on exertion (to
the point where she has had to crawl up stairs and sit down
while shopping) for which she has been evaluated by Dr.
[**Name (NI) **].
.
In terms of her chest pain and DOE, she describes both as
occurring together. The chest pain is present constantly,
ranging from severity of [**4-9**] to [**11-9**] and is worse with
movement, pressure to the chest wall, deep breathing, or
exertion. The shortness of breath is only with activity and does
not occur at rest. She describes the chest pain as pressure-like
in quality and occuring in the center chest to beneath the left
breast. She has had these symptoms for several months but feels
that they have been getting worse recently. She has had a cough
for about the last two months which is occasionally productive
of white sputum; she initially thought that this was due to a
cold and had some associated runny nose, though now feels cough
is not due to URI as it has persisted.
.
She underwent echocardiogram in [**5-/2133**] which showed mild LVH
with preserved ejection fraction (> 55%) and was otherwise
unrevealing in terms of etiology for her dyspnea. In addition,
she has had periodic complaints of heart palpitations for which
she was been monitored by [**Doctor Last Name **] of Hearts; 7 symptomatic episodes
revealed sinus rhythm at rate 60s-80s with occasional APBs and
atrial bigeminy.  She did undergo stress test back in [**2124**] by
Persantine MIBI which was negative for ischemia, but has had no
further stress testing since that time. Currently, she is
awaiting ophthalmologic procedure for her eye discomfort, and
her ophthalmologist at Mass Eye & Ear has recommended complete
cardiac work up prior to this procedure (details unclear as
notes are out of our system; however, per Dr.[**Name (NI) 21558**] clinic
note from [**2133-8-13**] it is "non urgent"). In addition, per Dr. [**Name (NI) 21559**] note from [**2133-6-12**], cardiac catheterization is
indicated to evaluate for left main disease prior to surgery
requiring monitored anesthesia care, as well as to further
evaluate for coronary artery disease given her multiple risk
factors for atherosclerosis.  She had cardiac catheterization
planned recently, although this procedure was cancelled given
her aspirin allergy and the possible need for intervention. The
patient was given the option of waiting for allergy appointment
to further evaluate this allergy or for CCU admission for rapid
desensitization, and chose the latter.
.
On review of systems, she denies any recent fever, chills,
nightsweats or rigors. She denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery. No PND or clear orthopnea (must sleep on her side
secondary to back/spine pain). She does have swelling of the
ankles which has been stable, as well as swelling in the knees
from her arthritis (L > R). She has had palpitations for which
sh has worn KOH monitor as above. She has multiple myalgias and
joint pains for which she is followed in rheumatology clinic;
these are stable. Cough as per HPI with no hemoptysis. No
N/V/D/C, no abdominal pain, no changes in bowel habits (last BM
this morning, normal), no black stools or red stools. She has
had several episodes of LH over the past several days, most
recently two days ago when she felt lightheaded after getting
out of a car and had to sit and hold her head. No syncope. No
dysuria or hematuria. All of the other review of systems were
negative.

MEDICAL HISTORY: 1. Spinal stenosis
2. Fibromylagia/Polymyalgia rheumatica
3. Hypertension
4. Osteoarthritis
5. Depression
6. s/p bilateral oopherectomy
7. Glucose intolerance

MEDICATION ON ADMISSION: - Premarin 0.9 mg PO daily (dose recently decreased per patient)
- Voltaren 1% gel apply to affected area QID PRN pain (not
currently using)
- Folic acid 1 mg PO daily
- Furosemide 10 mg PO daily (actual dose unclear)
- Gabapentin 300 mg PO QID (takes TID per patient)
- Isosorbide mononitrate ER-24 hr 30 mg PO daily
- Metoprolol tartrate 25 mg PO BID
- Mirtazapine 7.5 mg PO QHS
- Omeprazole 20 mg PO daily
- Sulfasalazine 1500 mg PO BID
- Venlafaxine 75 mg PO daily
- Acetaminophen 325 mg TID PRN cold symptoms (not currently
taking)
- Calcium carbonate-vitamin D3 600 mg-200 unit tablet PO BID
- Vitamin B12 1,000 mcg PO daily

ALLERGIES: Aspirin / Ultram / Vioxx / Percocet / Vicodin / Cephalexin

PHYSICAL EXAM: ADMISSION EXAM:
VS: T=none at time of exam BP=116/74 HR=77 RR=20 O2 sat=91% on
RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI though patient has pain in
her left eye with upward gaze.  Erythema and irritation of
medial sclera of right eye, involving [**Doctor First Name 2281**], with overlying
opacification. Left pupil has irregular contours and is slightly
larger than the right, though still reactive. Conjunctiva were
pale pink. No pallor or cyanosis of the oral mucosa; upper and
lower dentures in place. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: Slightly distant S1, S2 with no appreciable M/R/G. TTP
over most of anterior chest wall especially at costosternal
joints on the left.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
BACK: Signficant tenderness to palpation of all vertebrae and
also with tapping at CVA bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. +NABS.
EXTREMITIES: Non-pitting 1+ lower extremity edema, symmetric, no
calf tenderness. DP 2+ PT 2+ bilaterally.
.
DISCHARGE EXAM:
Vitals - Tm/Tc: 98.1/97.2 BP: 116-136/60-70 HR: 64-93 RR:18 02
sat: 99-96 RA, 95-97% on RA with ambulation.
In/Out: Last 24H: 1540/BRP
Weight 64.5kg (65)
GENERAL: elderly female in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+. right brachial cath site with
mild TTP but no erythema.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
unsteady without cane.
SKIN: no rash

FAMILY HISTORY: Denies cancer and cardiovascular problems in family.

SOCIAL HISTORY: Denies alcohol and drugs.  Distant history of trying cigarettes
many years ago.  Married to husband.  [**Name (NI) **] involved and
translates for her.  Persian.
Acute on chronic diastolic heart failure,Need for desensitization to allergens,Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Bronchiectasis without acute exacerbation,Visual discomfort,Personal history of allergy to analgesic agent,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified anemias,Osteoarthrosis, generalized, multiple sites,Knee joint replacement
Ac on chr diast hrt fail,Desensitiza to allergens,Crnry athrscl natve vssl,Angina pectoris NEC/NOS,Hypertension NOS,Chr pulmon heart dis NEC,Bronchiectas w/o ac exac,Visual discomfort,Hx-analgesic allergy,DMII wo cmp nt st uncntr,Anemia NEC,General osteoarthrosis,Joint replaced knee
Admission Date:  [**2133-8-16**]              Discharge Date:   [**2133-8-19**]

Date of Birth:  [**2053-5-7**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Ultram / Vioxx / Percocet / Vicodin / Cephalexin

Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Exertional Angina

Major Surgical or Invasive Procedure:
right and left cardiac catheterization


History of Present Illness:
History is obtained from the medical record and from the patient
with her son serving as interpreter. Please see also OMR notes
by Dr. [**Last Name (STitle) **] from [**2133-8-13**] and Dr. [**Name (NI) **] from [**2133-6-12**] for
additional information. Briefly, Ms. [**Known lastname 21557**] is a 80 year old
Persian woman who has multiple medical problems including
diet-controlled type II diabetes, hypertension, chronic joint
pain (osteoarthritis and seronegative RA vs. PMR), and recent
visual problems with ocular discomfort. She has had recent
complaints of chest pain and progressive dyspnea on exertion (to
the point where she has had to crawl up stairs and sit down
while shopping) for which she has been evaluated by Dr.
[**Name (NI) **].
.
In terms of her chest pain and DOE, she describes both as
occurring together. The chest pain is present constantly,
ranging from severity of [**4-9**] to [**11-9**] and is worse with
movement, pressure to the chest wall, deep breathing, or
exertion. The shortness of breath is only with activity and does
not occur at rest. She describes the chest pain as pressure-like
in quality and occuring in the center chest to beneath the left
breast. She has had these symptoms for several months but feels
that they have been getting worse recently. She has had a cough
for about the last two months which is occasionally productive
of white sputum; she initially thought that this was due to a
cold and had some associated runny nose, though now feels cough
is not due to URI as it has persisted.
.
She underwent echocardiogram in [**5-/2133**] which showed mild LVH
with preserved ejection fraction (> 55%) and was otherwise
unrevealing in terms of etiology for her dyspnea. In addition,
she has had periodic complaints of heart palpitations for which
she was been monitored by [**Doctor Last Name **] of Hearts; 7 symptomatic episodes
revealed sinus rhythm at rate 60s-80s with occasional APBs and
atrial bigeminy.  She did undergo stress test back in [**2124**] by
Persantine MIBI which was negative for ischemia, but has had no
further stress testing since that time. Currently, she is
awaiting ophthalmologic procedure for her eye discomfort, and
her ophthalmologist at Mass Eye & Ear has recommended complete
cardiac work up prior to this procedure (details unclear as
notes are out of our system; however, per Dr.[**Name (NI) 21558**] clinic
note from [**2133-8-13**] it is "non urgent"). In addition, per Dr. [**Name (NI) 21559**] note from [**2133-6-12**], cardiac catheterization is
indicated to evaluate for left main disease prior to surgery
requiring monitored anesthesia care, as well as to further
evaluate for coronary artery disease given her multiple risk
factors for atherosclerosis.  She had cardiac catheterization
planned recently, although this procedure was cancelled given
her aspirin allergy and the possible need for intervention. The
patient was given the option of waiting for allergy appointment
to further evaluate this allergy or for CCU admission for rapid
desensitization, and chose the latter.
.
On review of systems, she denies any recent fever, chills,
nightsweats or rigors. She denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery. No PND or clear orthopnea (must sleep on her side
secondary to back/spine pain). She does have swelling of the
ankles which has been stable, as well as swelling in the knees
from her arthritis (L > R). She has had palpitations for which
sh has worn KOH monitor as above. She has multiple myalgias and
joint pains for which she is followed in rheumatology clinic;
these are stable. Cough as per HPI with no hemoptysis. No
N/V/D/C, no abdominal pain, no changes in bowel habits (last BM
this morning, normal), no black stools or red stools. She has
had several episodes of LH over the past several days, most
recently two days ago when she felt lightheaded after getting
out of a car and had to sit and hold her head. No syncope. No
dysuria or hematuria. All of the other review of systems were
negative.


Past Medical History:
1. Spinal stenosis
2. Fibromylagia/Polymyalgia rheumatica
3. Hypertension
4. Osteoarthritis
5. Depression
6. s/p bilateral oopherectomy
7. Glucose intolerance

Social History:
Denies alcohol and drugs.  Distant history of trying cigarettes
many years ago.  Married to husband.  [**Name (NI) **] involved and
translates for her.  Persian.


Family History:
Denies cancer and cardiovascular problems in family.

Physical Exam:
ADMISSION EXAM:
VS: T=none at time of exam BP=116/74 HR=77 RR=20 O2 sat=91% on
RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI though patient has pain in
her left eye with upward gaze.  Erythema and irritation of
medial sclera of right eye, involving [**Doctor First Name 2281**], with overlying
opacification. Left pupil has irregular contours and is slightly
larger than the right, though still reactive. Conjunctiva were
pale pink. No pallor or cyanosis of the oral mucosa; upper and
lower dentures in place. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: Slightly distant S1, S2 with no appreciable M/R/G. TTP
over most of anterior chest wall especially at costosternal
joints on the left.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
BACK: Signficant tenderness to palpation of all vertebrae and
also with tapping at CVA bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. +NABS.
EXTREMITIES: Non-pitting 1+ lower extremity edema, symmetric, no
calf tenderness. DP 2+ PT 2+ bilaterally.
.
DISCHARGE EXAM:
Vitals - Tm/Tc: 98.1/97.2 BP: 116-136/60-70 HR: 64-93 RR:18 02
sat: 99-96 RA, 95-97% on RA with ambulation.
In/Out: Last 24H: 1540/BRP
Weight 64.5kg (65)
GENERAL: elderly female in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+. right brachial cath site with
mild TTP but no erythema.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
unsteady without cane.
SKIN: no rash


Pertinent Results:
ADMISSION LABS
[**2133-8-16**] 03:50PM   GLUCOSE-153* UREA N-23* CREAT-1.0 SODIUM-142
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
[**2133-8-16**] 03:50PM   CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2133-8-16**] 03:50PM   WBC-6.3 RBC-3.67* HGB-11.4* HCT-33.7* MCV-92#
MCH-31.1 MCHC-33.8 RDW-13.6
[**2133-8-16**] 03:50PM   NEUTS-60.4 LYMPHS-29.3 MONOS-6.0 EOS-3.5
BASOS-0.8
[**2133-8-16**] 03:50PM   PLT COUNT-238
[**2133-8-16**] 03:50PM   PT-11.9 PTT-25.2 INR(PT)-1.0

DISCHARGE LABS
[**2133-8-19**] 06:25AM BLOOD WBC-5.7 RBC-3.84* Hgb-12.1 Hct-35.9*
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.9 Plt Ct-219
[**2133-8-19**] 06:25AM BLOOD Plt Ct-219
[**2133-8-19**] 06:25AM BLOOD Glucose-133* UreaN-26* Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-31 AnGap-14

CXR ([**2133-8-16**]):
In comparison with the study of [**6-24**], there are lower lung
volumes that accentuate the prominence of the transverse
diameter of the heart. There is fullness of indistinct pulmonary
vessels consistent with elevated pulmonary venous pressure,
beyond that which would be expected with poor inspiration on a
portable examination.

Cardiac Cath ([**2133-8-17**]):
1. Selective coronary angiography of this right dominant system
revealed
no angiographically-apparent flow-limiting stenoses.  The LMCA
was free
from angiographic disease.  The LAD had mild plaquing. The
ostial
diagonal branch demonstrated 60% focal stenosis.  The LCx was a
small
vessel giving rise to a large OM1 (functionally a ramus
intermedis) and
four other tiny OMs.  The RCA was a large dominant vessel with
mild
plaquing.

2. Resting hemodynamics revealed elevated right and left-sided
filling
pressures with RVEDP of 12 mm Hg and LVEDP of 18 mm Hg. There
was
moderate pulmonary arterial systolic hypertension with PASP of
52 mm Hg.
The cardiac index was preserved at 3.17 L/min/m2.  There was
significant
systemic arterial systolic hypertension with SBP 181 mmHg.
Diastolic
blood pressures was 82 mm Hg.


Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
80 F with multiple medical problems and recent complaints of
worsening dyspnea on exertion who presents for planned CCU
admission for aspirin desensitization prior to cardiac
catheterization for further work up of DOE.
.
ACTIVE DIAGNOSES:
.
# Diastolic CHF: Pt has diastolic CHF based on cardiac cath, and
given the absence of coronary disease, this is likely the cause
of her exertional dyspnea. This is consistent with her
longstanding history of HTN. She was diuresed with IV lasix and
her home lasix was increased to 20mg po daily. She was also
started on metoprolol succinate 50 mg qday and lisinopril 2.5mg
po qday. At the time of discharge she was asymptomatic and her
weight was 64.5kg.
.
# Pulmonary HTN: Pt has significant pulmonary HTN (PA pressure
52/18/20) based on cardiac cath, and this is likely also
contributing to exertional dyspnea. This is likely [**3-4**] her left
sided diastolic CHF, but given history of bronchiectasis, cannot
rule out a primary pulmonary component to her elevated PA
pressures. She was discarged on ACEI, diuretic and beta blocker
per above.
.
# ASA Allergy: Pt underwent successful ASA desensitization. ASA
reaction is documented as urticaria/angioedema, but during
desensitization she only experienced pruritis without other
manifestations of hypersensitivity. She was desensitized per
[**Hospital1 18**] protocol without indicent and should continue taking ASA
81 indefinately to prevent recurrence of hypersensitivity.
.
# HTN: Her metoprolol tartrate 25mg qday was changed to
metoprolol succinate 50mg qday. Her lasix was increaed to 10mg
qday and she was started on lisinopril 2.5mg qday. Her BP was
well controlled on this regemin while hospitalzied, but her
medications should be further titrated by her PCP as an
outpatient.
.
CHRONIC DIAGNOSES:
.
# DIABETES: Last HbA1c in [**1-/2133**] was 5.7%. Currently off all
medication. She was covered with ISS while in house her BG was
well controlled
.
# ANEMIA: Her home folic acid and B12 were continued. Her Hct
remained stable in the low/normal range throughout her hospital
course and no intervention was undertaken.
.
# JOINT PAIN: Multifactorial (has RA vs. PMR and osteoarthritis
by history, also status post bilateral total knee arthroplasty).
She was continued on her home Voltaren 1% gel, sulfasalazine and
Ca/Vit D and her pain was well controlled on tylenol prn. Pt is
followed by rheum, who will see her as an outpatient.
.
# VASOACTIVE SYMPTOMS S/P MENOPAUSE: She was continued on her
home Premarin 0.9 mg PO daily; should follow up with PCP
regarding weaning estrogen.
.
# PSYCHIATRIC ISSUES: She was contined on her home mirtazapine
and venlafaxine.
.
TRANSITIONAL ISSUES: She was discahrged home with Cardiology,
PCP, [**Name10 (NameIs) 1957**] and Allergy/Immunology follow up. Dietary teaching
was performed regarding the importance of low Na diet and
warning signs about fluid overload.


Medications on Admission:
- Premarin 0.9 mg PO daily (dose recently decreased per patient)
- Voltaren 1% gel apply to affected area QID PRN pain (not
currently using)
- Folic acid 1 mg PO daily
- Furosemide 10 mg PO daily (actual dose unclear)
- Gabapentin 300 mg PO QID (takes TID per patient)
- Isosorbide mononitrate ER-24 hr 30 mg PO daily
- Metoprolol tartrate 25 mg PO BID
- Mirtazapine 7.5 mg PO QHS
- Omeprazole 20 mg PO daily
- Sulfasalazine 1500 mg PO BID
- Venlafaxine 75 mg PO daily
- Acetaminophen 325 mg TID PRN cold symptoms (not currently
taking)
- Calcium carbonate-vitamin D3 600 mg-200 unit tablet PO BID
- Vitamin B12 1,000 mcg PO daily

Discharge Medications:
1. conjugated estrogens 0.3 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).

8. sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
9. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
10. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO twice a day.
11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
13. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Acute on Chronic Diastolic Constestive heart failure
Aspirin Desensitization
Hypertension
Chronic Joint pain
Coronary artery disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted for a cardiac catheterization to test for
heart problems that were causing your breathing trouble and
chest pain. You did not have any significant blockages in your
heart arteries but we did find that you had too much fluid in
your body that wa affecting your breathing and making you tired.
We gave you some intravenous furosemide to get rid of the fluid
and will have you take 20 mg of furosemide daily instead of 10
mg to keep the fluid from coming back. If your breathing worsens
again, this means that the fluid is coming back. Weigh yourself
every morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3
lbs in 1 day or 5 pounds in 3 days. It is very important that
you avoid salt in your cooking and check the ingredients for
high salt content. You can have about 2000mg of salt daily.
.
We made the following changes to your medicines:
1. Increase furosemide to 20 mg daily
2. Stop taking metoprolol tartrate, take metoprolol succinate
instead once a day
3. Start aspirin 81 mg daily, do not stop taking this medicine
unless Dr. [**First Name (STitle) 21560**] tells you to.
4. Start lisinopril 2.5 mg daily to lower your blood pressure.

Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2133-8-26**] at 10:10 AM
With: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2133-9-1**] at 4:45 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2133-9-9**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 9316**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: THURSDAY [**2133-9-10**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
{'Acute on chronic diastolic heart failure,Need for desensitization to allergens,Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Bronchiectasis without acute exacerbation,Visual discomfort,Personal history of allergy to analgesic agent,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified anemias,Osteoarthrosis, generalized, multiple sites,Knee joint replacement'}


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: Exertional Angina

PRESENT ILLNESS: History is obtained from the medical record and from the patient
with her son serving as interpreter. Please see also OMR notes
by Dr. [**Last Name (STitle) **] from [**2133-8-13**] and Dr. [**Name (NI) **] from [**2133-6-12**] for
additional information. Briefly, Ms. [**Known lastname 21557**] is a 80 year old
Persian woman who has multiple medical problems including
diet-controlled type II diabetes, hypertension, chronic joint
pain (osteoarthritis and seronegative RA vs. PMR), and recent
visual problems with ocular discomfort. She has had recent
complaints of chest pain and progressive dyspnea on exertion (to
the point where she has had to crawl up stairs and sit down
while shopping) for which she has been evaluated by Dr.
[**Name (NI) **].
.
In terms of her chest pain and DOE, she describes both as
occurring together. The chest pain is present constantly,
ranging from severity of [**4-9**] to [**11-9**] and is worse with
movement, pressure to the chest wall, deep breathing, or
exertion. The shortness of breath is only with activity and does
not occur at rest. She describes the chest pain as pressure-like
in quality and occuring in the center chest to beneath the left
breast. She has had these symptoms for several months but feels
that they have been getting worse recently. She has had a cough
for about the last two months which is occasionally productive
of white sputum; she initially thought that this was due to a
cold and had some associated runny nose, though now feels cough
is not due to URI as it has persisted.
.
She underwent echocardiogram in [**5-/2133**] which showed mild LVH
with preserved ejection fraction (> 55%) and was otherwise
unrevealing in terms of etiology for her dyspnea. In addition,
she has had periodic complaints of heart palpitations for which
she was been monitored by [**Doctor Last Name **] of Hearts; 7 symptomatic episodes
revealed sinus rhythm at rate 60s-80s with occasional APBs and
atrial bigeminy.  She did undergo stress test back in [**2124**] by
Persantine MIBI which was negative for ischemia, but has had no
further stress testing since that time. Currently, she is
awaiting ophthalmologic procedure for her eye discomfort, and
her ophthalmologist at Mass Eye & Ear has recommended complete
cardiac work up prior to this procedure (details unclear as
notes are out of our system; however, per Dr.[**Name (NI) 21558**] clinic
note from [**2133-8-13**] it is "non urgent"). In addition, per Dr. [**Name (NI) 21559**] note from [**2133-6-12**], cardiac catheterization is
indicated to evaluate for left main disease prior to surgery
requiring monitored anesthesia care, as well as to further
evaluate for coronary artery disease given her multiple risk
factors for atherosclerosis.  She had cardiac catheterization
planned recently, although this procedure was cancelled given
her aspirin allergy and the possible need for intervention. The
patient was given the option of waiting for allergy appointment
to further evaluate this allergy or for CCU admission for rapid
desensitization, and chose the latter.
.
On review of systems, she denies any recent fever, chills,
nightsweats or rigors. She denies prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery. No PND or clear orthopnea (must sleep on her side
secondary to back/spine pain). She does have swelling of the
ankles which has been stable, as well as swelling in the knees
from her arthritis (L > R). She has had palpitations for which
sh has worn KOH monitor as above. She has multiple myalgias and
joint pains for which she is followed in rheumatology clinic;
these are stable. Cough as per HPI with no hemoptysis. No
N/V/D/C, no abdominal pain, no changes in bowel habits (last BM
this morning, normal), no black stools or red stools. She has
had several episodes of LH over the past several days, most
recently two days ago when she felt lightheaded after getting
out of a car and had to sit and hold her head. No syncope. No
dysuria or hematuria. All of the other review of systems were
negative.

MEDICAL HISTORY: 1. Spinal stenosis
2. Fibromylagia/Polymyalgia rheumatica
3. Hypertension
4. Osteoarthritis
5. Depression
6. s/p bilateral oopherectomy
7. Glucose intolerance

MEDICATION ON ADMISSION: - Premarin 0.9 mg PO daily (dose recently decreased per patient)
- Voltaren 1% gel apply to affected area QID PRN pain (not
currently using)
- Folic acid 1 mg PO daily
- Furosemide 10 mg PO daily (actual dose unclear)
- Gabapentin 300 mg PO QID (takes TID per patient)
- Isosorbide mononitrate ER-24 hr 30 mg PO daily
- Metoprolol tartrate 25 mg PO BID
- Mirtazapine 7.5 mg PO QHS
- Omeprazole 20 mg PO daily
- Sulfasalazine 1500 mg PO BID
- Venlafaxine 75 mg PO daily
- Acetaminophen 325 mg TID PRN cold symptoms (not currently
taking)
- Calcium carbonate-vitamin D3 600 mg-200 unit tablet PO BID
- Vitamin B12 1,000 mcg PO daily

ALLERGIES: Aspirin / Ultram / Vioxx / Percocet / Vicodin / Cephalexin

PHYSICAL EXAM: ADMISSION EXAM:
VS: T=none at time of exam BP=116/74 HR=77 RR=20 O2 sat=91% on
RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI though patient has pain in
her left eye with upward gaze.  Erythema and irritation of
medial sclera of right eye, involving [**Doctor First Name 2281**], with overlying
opacification. Left pupil has irregular contours and is slightly
larger than the right, though still reactive. Conjunctiva were
pale pink. No pallor or cyanosis of the oral mucosa; upper and
lower dentures in place. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: Slightly distant S1, S2 with no appreciable M/R/G. TTP
over most of anterior chest wall especially at costosternal
joints on the left.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
BACK: Signficant tenderness to palpation of all vertebrae and
also with tapping at CVA bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. +NABS.
EXTREMITIES: Non-pitting 1+ lower extremity edema, symmetric, no
calf tenderness. DP 2+ PT 2+ bilaterally.
.
DISCHARGE EXAM:
Vitals - Tm/Tc: 98.1/97.2 BP: 116-136/60-70 HR: 64-93 RR:18 02
sat: 99-96 RA, 95-97% on RA with ambulation.
In/Out: Last 24H: 1540/BRP
Weight 64.5kg (65)
GENERAL: elderly female in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. DPs, PTs 1+. right brachial cath site with
mild TTP but no erythema.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. Gait
unsteady without cane.
SKIN: no rash

FAMILY HISTORY: Denies cancer and cardiovascular problems in family.

SOCIAL HISTORY: Denies alcohol and drugs.  Distant history of trying cigarettes
many years ago.  Married to husband.  [**Name (NI) **] involved and
translates for her.  Persian. 

### Response:
{'Acute on chronic diastolic heart failure,Need for desensitization to allergens,Coronary atherosclerosis of native coronary artery,Other and unspecified angina pectoris,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Bronchiectasis without acute exacerbation,Visual discomfort,Personal history of allergy to analgesic agent,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified anemias,Osteoarthrosis, generalized, multiple sites,Knee joint replacement'}
