CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: The patient is an 89-year-old
female with a history of coronary artery disease, status post
myocardial infarction, atrial fibrillation and interstitial
lung disease who presented to the [**Hospital3 3834**] on
[**2155-6-1**] with a chief complaint of chest pain.  The patient
reported making her bed on the morning of [**6-1**] when she
collapsed.  The patient denied prodrome or loss of
consciousness.  She noted epigastric pain, nausea, but denied
chest pain, shortness of breath, diaphoresis at the time.  At
the outside hospital, the patient had a creatinine of 1.7, CK
of 138, MB of 12 with an index of 9.2 and a troponin of 2.54.
Electrocardiogram showed ST elevations of 4 to 5 mm in leads
2, 3 as well as in the right sided leads.  The patient had a
Q wave in 4 and F.  She was transferred to [**Hospital6 1760**] for catheter.  In the
catheter lab, she had elevated right sided pressures with a
right atrial pressure of 13 and RVEDP of 13 and dip and
plateau physiology.  Ejection fraction was 45%.  The patient
had severe inferior hypokinesis.  No lytics were given at the
outside hospital.  There was no intervention taken in the
catheter lab.  The patient was transferred to the C-Med floor
and at 9 p.m. on the night of the procedure, the patient
developed hypertension and bradycardia.  She did not respond
to atropine.  She could not be paced transcutaneously and was
started on dopamine and transferred to the CCU.

MEDICAL HISTORY: 1.  Coronary artery disease, status post myocardial
infarction
2.  Atrial fibrillation
3.  Interstitial lung disease
4.  Hypertension
5.  Status post tonsillectomy

MEDICATION ON ADMISSION: 

ALLERGIES: METOPROLOL WHICH CAUSES A RASH.

PHYSICAL EXAM: VITAL SIGNS:  The patient's pulse was 70, blood pressure
133/50, respiratory rate of 21 and oxygen saturation of 98%
on 100% nonrebreather.
GENERAL:  The patient was an ill appearing female in no
apparent distress.  She was agitated.
HEAD, EARS, EYES, NOSE AND THROAT:  Extraocular muscles are
intact.  Pupils equally round and reactive to light, moist
mucous membranes.
NECK:  No lymphadenopathy.  There was jugular venous
distention that was difficult to assess.
CARDIAC:  Regular rate and rhythm, normal S1, S2 and no
murmurs, rubs or gallops.
PULMONARY:  Lungs are clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES:  No edema.  The patient had 2+ DP pulses.
RECTAL:  Guaiac positive.
NEUROLOGIC:  Patient was agitated.  She had a low hertz
tremor of the upper extremities.  She had movement in all
four extremities.  She had 2+ biceps, patellar and deep
tendon reflexes and downgoing plantar reflexes.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient is a family physician.  [**Name10 (NameIs) **]
lives with her [**Age over 90 **]-year-old husband.  Denies tobacco or
alcohol use.
Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Cerebral embolism with cerebral infarction,Acidosis,Congestive heart failure, unspecified,Other heart block,Methicillin susceptible pneumonia due to Staphylococcus aureus,Atrial fibrillation,Nonspecific abnormal findings in stool contents
AMI inferior wall, init,Cardiogenic shock,Crbl emblsm w infrct,Acidosis,CHF NOS,Other heart block,Meth sus pneum d/t Staph,Atrial fibrillation,Abn find-stool contents
Admission Date:  [**2155-6-2**]       Discharge Date:  [**2155-6-14**]


Service:

CHIEF COMPLAINT:  Chest pain

HISTORY OF PRESENT ILLNESS:  The patient is an 89-year-old
female with a history of coronary artery disease, status post
myocardial infarction, atrial fibrillation and interstitial
lung disease who presented to the [**Hospital3 3834**] on
[**2155-6-1**] with a chief complaint of chest pain.  The patient
reported making her bed on the morning of [**6-1**] when she
collapsed.  The patient denied prodrome or loss of
consciousness.  She noted epigastric pain, nausea, but denied
chest pain, shortness of breath, diaphoresis at the time.  At
the outside hospital, the patient had a creatinine of 1.7, CK
of 138, MB of 12 with an index of 9.2 and a troponin of 2.54.
Electrocardiogram showed ST elevations of 4 to 5 mm in leads
2, 3 as well as in the right sided leads.  The patient had a
Q wave in 4 and F.  She was transferred to [**Hospital6 1760**] for catheter.  In the
catheter lab, she had elevated right sided pressures with a
right atrial pressure of 13 and RVEDP of 13 and dip and
plateau physiology.  Ejection fraction was 45%.  The patient
had severe inferior hypokinesis.  No lytics were given at the
outside hospital.  There was no intervention taken in the
catheter lab.  The patient was transferred to the C-Med floor
and at 9 p.m. on the night of the procedure, the patient
developed hypertension and bradycardia.  She did not respond
to atropine.  She could not be paced transcutaneously and was
started on dopamine and transferred to the CCU.

PAST MEDICAL HISTORY:
1.  Coronary artery disease, status post myocardial
infarction
2.  Atrial fibrillation
3.  Interstitial lung disease
4.  Hypertension
5.  Status post tonsillectomy

ALLERGIES:  METOPROLOL WHICH CAUSES A RASH.

MEDICATIONS:
1.  Aspirin
2.  Hydrochlorothiazide
3.  Prempro

SOCIAL HISTORY:  The patient is a family physician.  [**Name10 (NameIs) **]
lives with her [**Age over 90 **]-year-old husband.  Denies tobacco or
alcohol use.

FAMILY HISTORY:  Noncontributory

PHYSICAL EXAM:
VITAL SIGNS:  The patient's pulse was 70, blood pressure
133/50, respiratory rate of 21 and oxygen saturation of 98%
on 100% nonrebreather.
GENERAL:  The patient was an ill appearing female in no
apparent distress.  She was agitated.
HEAD, EARS, EYES, NOSE AND THROAT:  Extraocular muscles are
intact.  Pupils equally round and reactive to light, moist
mucous membranes.
NECK:  No lymphadenopathy.  There was jugular venous
distention that was difficult to assess.
CARDIAC:  Regular rate and rhythm, normal S1, S2 and no
murmurs, rubs or gallops.
PULMONARY:  Lungs are clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES:  No edema.  The patient had 2+ DP pulses.
RECTAL:  Guaiac positive.
NEUROLOGIC:  Patient was agitated.  She had a low hertz
tremor of the upper extremities.  She had movement in all
four extremities.  She had 2+ biceps, patellar and deep
tendon reflexes and downgoing plantar reflexes.

PERTINENT LABORATORY FINDINGS:  The patient had a white blood
cell count of 17.6 with a hematocrit of 33.2 and platelets of
240.  Her creatinine was 1.1.  The patient had an anion gap
of 21.  CK was 972 with an MB of 133 and an index of 13.7.
This rose to 981 with an MB of 137.  The patient had a
lactate of 4.8.  The patient had an initial arterial blood
gases of pH 7.25, PCO2 of 33 and PAO2 of 393.  Repeat
revealed pH of 7.31, PCO2 of 33 and PAO2 of 368.
Electrocardiogram revealed a junctional escape rhythm at 40
with normal axis, right bundle branch block and ST elevations
in 3 and F and ST depressions in L.  Cardiac catheterization
revealed right atrial pressure of 13, RVDP of 13, LVEDP of
13.  Cardiac output was 4.53 with a cardiac index to 2.63.
The patient had a right dominant system with a mid LAD lesion
of 50%, left circumflex OM lesion of 40% and a proximal RCA
lesion of 50%.  The patient had a diagonal 40% to 50% lesion
and a distal PDA 80%.

SUMMARY OF HOSPITAL COURSE:  The patient is an 89-year-old
female, past medical history of coronary artery disease,
status post myocardial infarction, atrial fibrillation,
hypertension and interstitial lung disease who presented with
an IMI and RV extension and now with severe bradycardia and
hypertension.

1.  CARDIOVASCULAR:  The patient presented with a history of
coronary artery disease, status post myocardial infarction in
the past, now with inferior myocardial infarction, severe RV
extension with hypertension, bradycardia and cardiogenic
shock.  From a coronary artery disease standpoint, the
patient had three vessel disease with suspected RCA culprit
that had largely become patent by the time of the first
catheterization and there was no intervention performed.  The
patient has symptomatic bradycardia and hypotension.  On
transfer to the unit, the patient continued to have episodes
of bradycardia and hypotension despite dopamine.  It was
decided to take the patient back to the cardiac
catheterization lab for a second look.  There was no change.
Electrophysiology was consulted and felt that the patient's
bradycardia was likely related to AV dysfunction and that a
temporary pacing wire was not indicated at that point.  The
patient was maintained on aspirin, Plavix and Aggrastat.
From a myocardium standpoint, the patient had an IMI with RV
extension and elevated right ventricular pressures.  Because
of the patient's hypertension and RV infarcts, the patient
was aggressively volume resuscitated.

Bedside echocardiogram was done and revealed RV hypokinesis
and inferior hypokinesis, otherwise relatively normal LV
function.  From a conduction standpoint, the patient had a
junctional escape rhythm likely secondary to her ischemic
heart disease.  She had an initial response to dopamine with
increase in heart rate and blood pressure.  It was not felt
that the patient needed a temporary wire at that point.
Electrophysiology followed the patient.  The day after
admission to the CCU, the patient continued to have
hypotension and bradycardia not responding to inotropes and
.........otropes.  She had been switched from dopamine to
dobutamine.  Lactate continued to be elevated.  EP decided to
place a temporary pacing wire.  The patient also had a PA
catheter placed in order to monitor the patient and ensure a
physiologic cardiac output.  The patient required intubation
for control of her acidosis.  The day after temporary pacer
placement, the patient's cardiac output had improved.  It had
become evident that the patient's pacemaker had not been
capturing.  The EP fellow had been called and the set rate
was increased.  The patient had episodes of nonsustained
ventricular tachycardia thought to be secondary to dobutamine
and this was weaned off.  The patient's acid base status
improved with an improved cardiac output.  The patient was
markedly hypertensive in the post infarct and was started on
intravenous enalaprilat with little effect.  This was then
transitioned to intravenous hydralazine with excellent
results.  The temporary wire was removed.

The patient had an episode of tachypnea and shortness of
breath and a chest x-ray revealed some evidence of congestive
heart failure likely related to vigorous volume
resuscitation.  The patient responded excellently with 20 mg
intravenous of Lasix.  The patient had episodes of
nonsustained ventricular tachycardia in the setting of
relative bradycardia after the temporary wire was removed.
EP was reconsulted for possible placement of a new temporary
pacing wire versus permanent pacemaker placement.  The
patient's rhythm changed to atrial fibrillation.  She was
started on low molecular weight heparin.  Eventually, her
hydralazine was switched to captopril which she responded
very well to.  The patient ultimately underwent permanent
pacemaker placement.  The pacemaker was complicated by
episodes of ventricular tachycardia and ventricular
fibrillation in the EP lab after administration of ibutilide.
The patient was easily cardioverted with 200 joules.  The
patient had a repeat echocardiogram that had an ejection
fraction of greater than 55%, pulmonary artery hypertension,
severe global right ventricular hypokinesis, 1+ mitral
regurgitation and 2+ tricuspid regurgitation.  The patient
was eventually transitioned to oral anticoagulation.  She
will need to follow up with her outpatient cardiologist, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], in the electrophysiology device clinic.  The
patient was started on amiodarone 400 mg po tid.

2.  PULMONARY:  The patient was intubated for worsening acid
base status and overwhelming lactic acidosis.  With
improvement in her cardiac output, her acidosis improved
markedly.  She was able to be extubated within three days.
She was found to have a left lower lobe Methicillin sensitive
Staphylococcus aureus pneumonia and was started on oxacillin
with excellent clinical response.

3.  RENAL:  The patient presented with lactic gap acidosis
which resolved with mechanical ventilation and improved
cardiac output.  The patient's creatinine was elevated on
presentation, but returned to baseline level of 0.6.

4.  NEUROLOGIC:  The patient presented with agitation, mental
status changes which were thought to be secondary to poor
perfusion from decreased cardiac output.  It was also thought
that sedation as well as the patient's acid base status had a
role in her mental status changes.  The patient, post
extubation, had dysarthria without aphasia.  Her neurologic
exam showed no focal deficits.  Neurology was consulted and
recommended a CT.  CT scan revealed an old left temporal
cerebrovascular event.  The patient underwent MRI with DWI
which revealed a presence of a stroke in the left uncus which
did not correlate with the patient's dysarthria.  Neurology
and the stroke team recommended that the patient be
anticoagulated.  She was started on low molecular weight
heparin with the hope to transition her to Coumadin at the
time of discharge.  Her dysarthria improved slowly but
steadily throughout the admission.

5.  GASTROINTESTINAL:  The patient presented with guaiac
positive stools.  The patient had a relatively stable
hematocrit throughout her admission, although she did require
2 units of packed red blood cells on admission for anemia and
then 1 unit of packed red blood cells after her pacemaker
placement to keep her hematocrit greater than 30.  She did
not have any evidence of gastrointestinal bleed while in
hospital.

6.  HEMATOLOGIC:  The patient presented with platelets of
181.  After being started on intravenous heparin post
catheterization, the patient had declined in her platelets to
104 from an initial platelet count of 240.  The patient's
heparin products were held and a heparin dependent platelet
antibody was sent.  There was no evidence of heparin induced
thrombocytopenia.  The patient's heparin related antibody was
negative.  She was started on low molecular weight heparin
without any adverse effect to her platelets.  Her platelet
count returned to the 200s.

DISCHARGE CONDITION:  Stable

DISCHARGE STATUS:  The patient was discharged with follow up
in device clinic, as well as follow up with her cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], one to two weeks after discharge.  She will
likely have to go to acute rehabilitation.  The patient was
discharged on aspiration precautions and fall precautions.
She will have a cardiac diet.  The patient was evaluated by
the speech and swallow team who recommended that she be kept
on a soft consistency diet although able to take pills po.
She will be re-evaluated near the end of her admission for
her ability to swallow.

The remainder of this discharge summary will be dictated by
the intern that picks up this CCU service.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 8227**]

Dictated By:[**Last Name (NamePattern1) 5246**]
MEDQUIST36

D:  [**2155-6-13**]  11:29
T:  [**2155-6-13**]  12:54
JOB#:  [**Job Number 39891**]

cc:[**Last Name (NamePattern1) 39892**]
{'Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Cerebral embolism with cerebral infarction,Acidosis,Congestive heart failure, unspecified,Other heart block,Methicillin susceptible pneumonia due to Staphylococcus aureus,Atrial fibrillation,Nonspecific abnormal findings in stool contents'}


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: The patient is an 89-year-old
female with a history of coronary artery disease, status post
myocardial infarction, atrial fibrillation and interstitial
lung disease who presented to the [**Hospital3 3834**] on
[**2155-6-1**] with a chief complaint of chest pain.  The patient
reported making her bed on the morning of [**6-1**] when she
collapsed.  The patient denied prodrome or loss of
consciousness.  She noted epigastric pain, nausea, but denied
chest pain, shortness of breath, diaphoresis at the time.  At
the outside hospital, the patient had a creatinine of 1.7, CK
of 138, MB of 12 with an index of 9.2 and a troponin of 2.54.
Electrocardiogram showed ST elevations of 4 to 5 mm in leads
2, 3 as well as in the right sided leads.  The patient had a
Q wave in 4 and F.  She was transferred to [**Hospital6 1760**] for catheter.  In the
catheter lab, she had elevated right sided pressures with a
right atrial pressure of 13 and RVEDP of 13 and dip and
plateau physiology.  Ejection fraction was 45%.  The patient
had severe inferior hypokinesis.  No lytics were given at the
outside hospital.  There was no intervention taken in the
catheter lab.  The patient was transferred to the C-Med floor
and at 9 p.m. on the night of the procedure, the patient
developed hypertension and bradycardia.  She did not respond
to atropine.  She could not be paced transcutaneously and was
started on dopamine and transferred to the CCU.

MEDICAL HISTORY: 1.  Coronary artery disease, status post myocardial
infarction
2.  Atrial fibrillation
3.  Interstitial lung disease
4.  Hypertension
5.  Status post tonsillectomy

MEDICATION ON ADMISSION: 

ALLERGIES: METOPROLOL WHICH CAUSES A RASH.

PHYSICAL EXAM: VITAL SIGNS:  The patient's pulse was 70, blood pressure
133/50, respiratory rate of 21 and oxygen saturation of 98%
on 100% nonrebreather.
GENERAL:  The patient was an ill appearing female in no
apparent distress.  She was agitated.
HEAD, EARS, EYES, NOSE AND THROAT:  Extraocular muscles are
intact.  Pupils equally round and reactive to light, moist
mucous membranes.
NECK:  No lymphadenopathy.  There was jugular venous
distention that was difficult to assess.
CARDIAC:  Regular rate and rhythm, normal S1, S2 and no
murmurs, rubs or gallops.
PULMONARY:  Lungs are clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended with normoactive
bowel sounds.
EXTREMITIES:  No edema.  The patient had 2+ DP pulses.
RECTAL:  Guaiac positive.
NEUROLOGIC:  Patient was agitated.  She had a low hertz
tremor of the upper extremities.  She had movement in all
four extremities.  She had 2+ biceps, patellar and deep
tendon reflexes and downgoing plantar reflexes.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient is a family physician.  [**Name10 (NameIs) **]
lives with her [**Age over 90 **]-year-old husband.  Denies tobacco or
alcohol use. 

### Response:
{'Acute myocardial infarction of other inferior wall, initial episode of care,Cardiogenic shock,Cerebral embolism with cerebral infarction,Acidosis,Congestive heart failure, unspecified,Other heart block,Methicillin susceptible pneumonia due to Staphylococcus aureus,Atrial fibrillation,Nonspecific abnormal findings in stool contents'}
