CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 54 yo F with CAD s/p 4 stents, +smoker, DM2, HTN, PVD,
hypercholesterolemia, family history of premature CAD now with
chest pain. She states she was sitting in her living room around
8 p.m. when she started to feel SOB. Went upstairs and sat on a
stool and states began to have CP. CP described as stabbing in
the middle to L chest, radiating to L arm and jaw. States she
was feeling hot but no diaphoresis, n/v. +SOB. Took 3 NTG each
15 mins apart with no relief so called EMS. States the pain was
similar to that she had when she had her previous MI's. EMS
found her tachycardic and gave 6 Adenocard, 25mg cardizem, 1"
nitropaste, and ASA.
.
At [**Hospital3 **] she arrived with a HR of 140 in Afib. BP was
195/106. Was given 25mg Cardizem. HR was still 140 and a
diltiazem drip was started. She converted to NSR with HR in the
60's and the diltiazem drip was stopped. Nitropaste was removed.
Trop was was 0.16 and ECG was concerning for ST elevations and
pt was sent in helicopter to [**Hospital1 18**] for possible cath.
.
On arrival to [**Hospital1 18**] pt stated she was having some CP and was
started on nitro gtt. CP went away, but nitro was titrated up to
90 mcg for
high systolic BP's in the 180's-190's. HR in the 60's. She was
given 25mg metoprolol po and 12.5mg captopril po. Stated she
still had a small tingling sensation in her L jaw, and c/o
headache, but otherwise was CP free.
.
She states she has been having CP with SOB at least 1-2 times
per week for the last few weeks. States it comes on both at rest
and when she is walking or doing other activities. States
exerting herself does not bring on the CP. It usually resolves
with 2 NTG's and is accompanied by SOB. States lately the
episodes have been coming more often and seem to last longer.

MEDICAL HISTORY: -CAD s/p 4 stents at [**Hospital1 112**]
--Cath [**2147-12-27**] at [**Hospital1 18**] showed LAD with diffuse disease, 70%
focal stenosis mid segment. Stent placed to mid RCA. LVEF 45%
with global hypokinesis.
-HTN
-DM2
-h/o renal artery stenosis s/p B stents
-h/o PVD s/p stents in bilateral LE's
-hypercholesterolemia
-s/p partial hysterectomy
-s/p cholecystectomy
-Fatty liver
-h/o ETOH abuse
-obesity
-cerebral aneurysm clipping [**8-22**]

MEDICATION ON ADMISSION: Aspirin 325 daily
States she last saw her PCP 2 months ago who recommends she take
many other meds but she has not been able to afford them.

ALLERGIES: Penicillins / Codeine / Sulfa (Sulfonamides)

PHYSICAL EXAM: PE: 98.6 HR 72, BP 187/80, RR 16, O2sat 100% on 2L NC
Gen: in nad.
HEENT: PERRLA, EOMI, OP clear and moist.
CV: RRR, +[**12-28**] HSM at LUSB.
Lungs: CTAB
Abd: +ttp of RUQ. +bs. No rebound or guarding.
Ext: no c/c/e.
Pulses: no palpable pulse R groin, L femoral very faint. PT 2+
bilaterlly, DP: 2+ L, 1+ R.

FAMILY HISTORY: Mother had DM and died of MI at age 59. Father died of throat
and lung cancer age 61.

SOCIAL HISTORY: Lives with husband. [**Name (NI) **] 2 sons and one daughter. Is disabled s/p
aneurysm clipping. Smokes 1 ppd. Drinks a beer "once in awhile",
no h/o withdrawal sx's. Son is coming home from [**Country 2451**] today.
Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other complications due to other vascular device, implant, and graft,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Other specified disorders of arteries and arterioles,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Subendo infarct, initial,Acute kidney failure NOS,Comp-oth vasc dev/graft,Chr duoden ulcer w hem,Duodenitis w hmrhg,Hyp kid NOS w cr kid V,Crnry athrscl natve vssl,Abn react-procedure NEC,Accident in place NEC,Arterial disease NEC,Athscl extrm ntv art NOS,Atrial fibrillation,DMII wo cmp nt st uncntr
Admission Date:  [**2151-1-2**]              Discharge Date:   [**2151-1-9**]

Date of Birth:  [**2094-1-5**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Codeine / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 7202**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
cardiac catheterization with stent placement
angiography of mesenteric and renal arteries
esophagogastroduodenoscopy

History of Present Illness:
54 yo F with CAD s/p 4 stents, +smoker, DM2, HTN, PVD,
hypercholesterolemia, family history of premature CAD now with
chest pain. She states she was sitting in her living room around
8 p.m. when she started to feel SOB. Went upstairs and sat on a
stool and states began to have CP. CP described as stabbing in
the middle to L chest, radiating to L arm and jaw. States she
was feeling hot but no diaphoresis, n/v. +SOB. Took 3 NTG each
15 mins apart with no relief so called EMS. States the pain was
similar to that she had when she had her previous MI's. EMS
found her tachycardic and gave 6 Adenocard, 25mg cardizem, 1"
nitropaste, and ASA.
.
At [**Hospital3 **] she arrived with a HR of 140 in Afib. BP was
195/106. Was given 25mg Cardizem. HR was still 140 and a
diltiazem drip was started. She converted to NSR with HR in the
60's and the diltiazem drip was stopped. Nitropaste was removed.
Trop was was 0.16 and ECG was concerning for ST elevations and
pt was sent in helicopter to [**Hospital1 18**] for possible cath.
.
On arrival to [**Hospital1 18**] pt stated she was having some CP and was
started on nitro gtt. CP went away, but nitro was titrated up to
90 mcg for
high systolic BP's in the 180's-190's. HR in the 60's. She was
given 25mg metoprolol po and 12.5mg captopril po. Stated she
still had a small tingling sensation in her L jaw, and c/o
headache, but otherwise was CP free.
.
She states she has been having CP with SOB at least 1-2 times
per week for the last few weeks. States it comes on both at rest
and when she is walking or doing other activities. States
exerting herself does not bring on the CP. It usually resolves
with 2 NTG's and is accompanied by SOB. States lately the
episodes have been coming more often and seem to last longer.


Past Medical History:
-CAD s/p 4 stents at [**Hospital1 112**]
--Cath [**2147-12-27**] at [**Hospital1 18**] showed LAD with diffuse disease, 70%
focal stenosis mid segment. Stent placed to mid RCA. LVEF 45%
with global hypokinesis.
-HTN
-DM2
-h/o renal artery stenosis s/p B stents
-h/o PVD s/p stents in bilateral LE's
-hypercholesterolemia
-s/p partial hysterectomy
-s/p cholecystectomy
-Fatty liver
-h/o ETOH abuse
-obesity
-cerebral aneurysm clipping [**8-22**]


Social History:
Lives with husband. [**Name (NI) **] 2 sons and one daughter. Is disabled s/p
aneurysm clipping. Smokes 1 ppd. Drinks a beer "once in awhile",
no h/o withdrawal sx's. Son is coming home from [**Country 2451**] today.

Family History:
Mother had DM and died of MI at age 59. Father died of throat
and lung cancer age 61.

Physical Exam:
PE: 98.6 HR 72, BP 187/80, RR 16, O2sat 100% on 2L NC
Gen: in nad.
HEENT: PERRLA, EOMI, OP clear and moist.
CV: RRR, +[**12-28**] HSM at LUSB.
Lungs: CTAB
Abd: +ttp of RUQ. +bs. No rebound or guarding.
Ext: no c/c/e.
Pulses: no palpable pulse R groin, L femoral very faint. PT 2+
bilaterlly, DP: 2+ L, 1+ R.

Pertinent Results:
[**2151-1-2**] 02:05AM   WBC-13.2* RBC-4.27 HGB-12.6 HCT-36.0 MCV-84
MCH-29.5 MCHC-34.9 RDW-15.3
[**2151-1-2**] 02:05AM   PLT COUNT-286
[**2151-1-2**] 02:05AM   PT-12.0 PTT-22.7 INR(PT)-1.0
[**2151-1-2**] 02:05AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2151-1-2**] 02:05AM   CK-MB-13* MB INDX-12.3* cTropnT-0.16*
[**2151-1-2**] 02:05AM   LIPASE-48
[**2151-1-2**] 02:05AM   ALT(SGPT)-21 AST(SGOT)-33 CK(CPK)-106
AMYLASE-72 TOT BILI-0.2
[**2151-1-2**] 09:30AM   CK-MB-48* MB INDX-15.6* cTropnT-0.60*
[**2151-1-2**] 09:30AM   CK(CPK)-308*
[**2151-1-2**] 09:30AM   GLUCOSE-178* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
.
ECGs: at OSH: NSR at 66 nl axis, nl intervals, poor R wave
progression. Q in III. 2mm ST elevation in III comp to prior.
1mm ST elevation V2-V3 present on old ECG.
-at [**Hospital1 18**] 01:23 - NSR at 73, nl axis, nl intervals. TWI V6 old
comp to prior. 1mm ST elevations V1-V3 old comp to prior from
[**2147**].

Brief Hospital Course:
.
# CAD: She was diagnosed with a non-ST elevation MI and was
started on IV heparin and loaded with clopidogrel.  As she was
asymptomatic at the time, the plan was made to stabilize her
with antiplatelet agents and plan for catheterization on [**1-4**].
She had recurrent chest pain the next day and was started on
integrilin, after which time she was chest pain-free.  Her peak
CK was 347, MB 49, and troponin T 1.68.  She underwent cardiac
catheterization on [**1-4**], with PCI to the an 80% stenotic lesion
of the ostial RCA.  She was continued on ASA 325, Plavix,
lipitor 80, and beta blocker.  She had no further chest pain.
She was discharged to PCP follow up with establishment of
Cardiology follow up.
.
# CHF:  TTE on [**1-5**] with EF 50%, mild LVH, mildly dilated
ascending aorta with no AI.  She was volume overloaded on exam
after her procedure and was diuresed with IV Lasix.  She was
maintained on a beta blocker, ACE-inhibitor, and oral Lasix.
She was euvolemic on discharge.
.
# Atrial fibrillation:  She has a history of paroxysmal atrial
fibrillation with RVR at the outside hospital that converted
with diltiazem.  She had an episode of RVR in CCU, that was
treated with diltiazem gtt, after which she converted to NSR.
She was maintained on a beta blocker and was in sinus rhythm on
discharge.  She was not started on anticoagulation due to her
recent GI bleed.
.
# HTN:  She is not adherent to her medication regimen as an
outpatient.  Her hypertension was thought to be a likely trigger
for her AF w/ RVR.  She was severely hypertensive in the CCU to
the 230s/100s.  Her blood pressure was controlled in the CCU
with labetalol and nifedipine gtt.  She was hypertensive off the
drips on the floor.  Her severe renal artery stenosis was
thought to be the main cause for her refractory hypertension.
She was discharged on carvedilol, lisinopril, and furosemide.
She was discharged to follow up with her PCP for further
titration of her medications.
.
# GI bleed:  She had melenic stools in the cath holding area on
[**1-4**] while on aspirin, clopidogrel, IV heparin, and integrilin.
She had patent celiac and mesenteric arteries on angiography, so
ischemic bowel was thought to be unlikely.  GI was consulted and
performed an EGD that showed gastric erosions and duodenitis as
the only sources of upper GI bleed.  She was started on IV
pantoprazole and carafate with close monitoring of her
hematocrit.  She required a total of 8U PRBC.  Her hematocrit
stabilized and her diet was advanced.  She had no further
episodes of melena during her stay.  She was encouraged to have
a colonoscopy as an outpatient as she has never had one before.
.
# RP bleed:  She had severe hypertension during the [**1-4**] cardiac
catheterization requiring nitroprusside.  Her renal arteries
were engaged during the cath, and she was found to have severe
in-stent restenosis of her right renal artery, but attempts at
intervention were unsuccessful.  In the cath holding area, she
became hypotensive and had a large melenic stool.  She was taken
back to the cath lab where she was found to have patent celiac
and superior mesenteric arteries, but had bleeding from the
right kidney which was stopped with balloon tamponade.  No
further chest pain.  A CT abdomen was performed that showed a
large perinephric hematoma extending into the retroperitoneum.
Transplant Surgery was following.  Surgical intervention was not
indicated as she was hemodynamically stable.  Repeat CT showed
stable hematoma and her hematocrit stabilized.
.
# ARF:  She has known RAS s/p stenting, and was thought to
likely have some hypertensive nephropathy as well.  Her baseline
creatinine was unknown.  Her creatinine was 1.5 on the day of
cath, and her FENa was 0.9%, indicating a prerenal state.
Angiography showed right renal artery in-stent restenosis.  She
likely had some hypoperfusion to the R kidney in setting of
bleed.  She also received a large dye load for aniography of
coronaries, mesenterics, renals, and iliacs.  Her left kidney
appeared atrophic on imaging.  Her creatinine increased to 1.6
and was then stable for several days.  She was discharged on an
ACE-inhibitor, with PCP follow up for further management.
.
# Glucose intolerance:  She was hyperglycemic throughout her
stay.  She has no known diagnosis of diabetes.  Her HgA1C was
6.7.  She was maintained on an insulin sliding scale.
.
# Code status: FULL
.


Medications on Admission:
Aspirin 325 daily
States she last saw her PCP 2 months ago who recommends she take
many other meds but she has not been able to afford them.

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Gentiva

Discharge Diagnosis:
Primary:
Non-ST elevation MI
Congestive heart failure, systolic
GI bleed, source unknown
Hypertension
Renal artery stent restenosis
Renal failure, likely acute on chronic

Secondary:
Peripheral vascular disease
Primary:
Non-ST elevation MI
Congestive heart failure, systolic
GI bleed, source unknown
Hypertension
Renal artery stent restenosis
Renal failure, likely acute on chronic

Secondary:
Peripheral vascular disease


Discharge Condition:
good, hematocrit stable, chest pain free, BP fairly
well-controlled, creatinine stable


Discharge Instructions:
It is very important that you take all of your medications as
prescribed.
.
If you experience chest pain, shortness of breath, dizziness,
bloody or black stools, or other concerning symptoms, please
call your doctor or go to the ER.

Followup Instructions:
1) Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 24354**], to
schedule a follow up appointment within the next week.  You
should have your hematocrit and renal function labs checked.
Please discuss colonoscopy with Dr. [**First Name (STitle) **].


Completed by:[**2151-4-1**]
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other complications due to other vascular device, implant, and graft,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Other specified disorders of arteries and arterioles,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 54 yo F with CAD s/p 4 stents, +smoker, DM2, HTN, PVD,
hypercholesterolemia, family history of premature CAD now with
chest pain. She states she was sitting in her living room around
8 p.m. when she started to feel SOB. Went upstairs and sat on a
stool and states began to have CP. CP described as stabbing in
the middle to L chest, radiating to L arm and jaw. States she
was feeling hot but no diaphoresis, n/v. +SOB. Took 3 NTG each
15 mins apart with no relief so called EMS. States the pain was
similar to that she had when she had her previous MI's. EMS
found her tachycardic and gave 6 Adenocard, 25mg cardizem, 1"
nitropaste, and ASA.
.
At [**Hospital3 **] she arrived with a HR of 140 in Afib. BP was
195/106. Was given 25mg Cardizem. HR was still 140 and a
diltiazem drip was started. She converted to NSR with HR in the
60's and the diltiazem drip was stopped. Nitropaste was removed.
Trop was was 0.16 and ECG was concerning for ST elevations and
pt was sent in helicopter to [**Hospital1 18**] for possible cath.
.
On arrival to [**Hospital1 18**] pt stated she was having some CP and was
started on nitro gtt. CP went away, but nitro was titrated up to
90 mcg for
high systolic BP's in the 180's-190's. HR in the 60's. She was
given 25mg metoprolol po and 12.5mg captopril po. Stated she
still had a small tingling sensation in her L jaw, and c/o
headache, but otherwise was CP free.
.
She states she has been having CP with SOB at least 1-2 times
per week for the last few weeks. States it comes on both at rest
and when she is walking or doing other activities. States
exerting herself does not bring on the CP. It usually resolves
with 2 NTG's and is accompanied by SOB. States lately the
episodes have been coming more often and seem to last longer.

MEDICAL HISTORY: -CAD s/p 4 stents at [**Hospital1 112**]
--Cath [**2147-12-27**] at [**Hospital1 18**] showed LAD with diffuse disease, 70%
focal stenosis mid segment. Stent placed to mid RCA. LVEF 45%
with global hypokinesis.
-HTN
-DM2
-h/o renal artery stenosis s/p B stents
-h/o PVD s/p stents in bilateral LE's
-hypercholesterolemia
-s/p partial hysterectomy
-s/p cholecystectomy
-Fatty liver
-h/o ETOH abuse
-obesity
-cerebral aneurysm clipping [**8-22**]

MEDICATION ON ADMISSION: Aspirin 325 daily
States she last saw her PCP 2 months ago who recommends she take
many other meds but she has not been able to afford them.

ALLERGIES: Penicillins / Codeine / Sulfa (Sulfonamides)

PHYSICAL EXAM: PE: 98.6 HR 72, BP 187/80, RR 16, O2sat 100% on 2L NC
Gen: in nad.
HEENT: PERRLA, EOMI, OP clear and moist.
CV: RRR, +[**12-28**] HSM at LUSB.
Lungs: CTAB
Abd: +ttp of RUQ. +bs. No rebound or guarding.
Ext: no c/c/e.
Pulses: no palpable pulse R groin, L femoral very faint. PT 2+
bilaterlly, DP: 2+ L, 1+ R.

FAMILY HISTORY: Mother had DM and died of MI at age 59. Father died of throat
and lung cancer age 61.

SOCIAL HISTORY: Lives with husband. [**Name (NI) **] 2 sons and one daughter. Is disabled s/p
aneurysm clipping. Smokes 1 ppd. Drinks a beer "once in awhile",
no h/o withdrawal sx's. Son is coming home from [**Country 2451**] today. 

### Response:
{'Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Other complications due to other vascular device, implant, and graft,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Other specified disorders of arteries and arterioles,Atherosclerosis of native arteries of the extremities, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
