CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: This 63 y/o female with pain radiating to both arms for 30 days,
improved with leaning forward. .
In ED, initial VS - HR: 76 BP: 137/80 O2 Sat: 98. CXR showed
findings c/w COPD/emphysema. Mid-to-lower thoracic spine
compression fracture.
No acute findings. EKG showed no STEMI, no ischemic changes.
Cardiac enzymes negative x 1.
.
Of note, patient failed prior stress test at [**Hospital1 102643**]
medical management failed to control chest pain. Per discussion
with atrius cardiology, admission to caridology for
consideration of cath. Patient was heparinized in the ED.
Unfortunately, further records not available at this time.
.

MEDICAL HISTORY: COPD
Hypertension
Hyperlipidemia
s/p Tonsillectomy

MEDICATION ON ADMISSION: - fish oil 1000 mcg daily
- MVI
- asa 81 mg daily
- atenolol 25 mg daily
- isosorbide dinitrite 10 mg tid
- simvastatin 10 mg daily
- ativan 1 mg daily

ALLERGIES: Penicillins / epinephrine / caffeine

PHYSICAL EXAM: On Admission:
VS - 99.5, 141/83, 76, 20, 98 RA
GENERAL - well-appearing female in NAD, comfortable, appropriate

FAMILY HISTORY: Mom - CVA
[**Name (NI) **] - triple bypass, DM

SOCIAL HISTORY: positive for tobacco, reports social EtOH, no drugs. Reports 1
ppd tobacco x 40 years.
Coronary atherosclerosis of native coronary artery,Acidosis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Intermediate coronary syndrome,Body Mass Index less than 19, adult,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Anxiety state, unspecified,Other specified diseases of blood and blood-forming organs,Anemia, unspecified,Peripheral vascular disease, unspecified
Crnry athrscl natve vssl,Acidosis,Chr airway obstruct NEC,Atrial fibrillation,Intermed coronary synd,BMI less than 19,adult,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Anxiety state NOS,Blood diseases NEC,Anemia NOS,Periph vascular dis NOS
Admission Date:  [**2148-11-29**]              Discharge Date:   [**2148-12-12**]

Date of Birth:  [**2085-9-18**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillins / epinephrine / caffeine

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
[**2148-11-30**] left heart catheterization, coronary angiogram
[**2148-12-5**] Coronary artery bypass grafting
x3(LIMA-LAD,SVG-marg,SVG-PDA)

[**2148-11-30**] left heart catheterization, coronary angiogram
[**2148-12-5**] Coronary artery bypass grafting
x3(LIMA-LAD,SVG-marg,SVG-PDA)

[**2148-11-30**] left heart catheterization, coronary angiogram
[**2148-12-5**] Coronary artery bypass grafting
x3(LIMA-LAD,SVG-marg,SVG-PDA)


History of Present Illness:
This 63 y/o female with pain radiating to both arms for 30 days,
improved with leaning forward. .
In ED, initial VS - HR: 76 BP: 137/80 O2 Sat: 98. CXR showed
findings c/w COPD/emphysema. Mid-to-lower thoracic spine
compression fracture.
No acute findings. EKG showed no STEMI, no ischemic changes.
Cardiac enzymes negative x 1.
.
Of note, patient failed prior stress test at [**Hospital1 102643**]
medical management failed to control chest pain. Per discussion
with atrius cardiology, admission to caridology for
consideration of cath. Patient was heparinized in the ED.
Unfortunately, further records not available at this time.
.


Past Medical History:
COPD
Hypertension
Hyperlipidemia
s/p Tonsillectomy


Social History:
positive for tobacco, reports social EtOH, no drugs. Reports 1
ppd tobacco x 40 years.

Family History:
Mom - CVA
[**Name (NI) **] - triple bypass, DM

Physical Exam:
On Admission:
VS - 99.5, 141/83, 76, 20, 98 RA
GENERAL - well-appearing female in NAD, comfortable, appropriate

HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG appreciated, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait not assessed


Pertinent Results:
[**2148-12-5**] Intra-op TEE
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-50 %). The right ventricular cavity
is mildly dilated with mild global free wall hypokinesis. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is no pericardial
effusion.
POST CPB
1. Marginally improved biventricular systolci funjction with
background inotropic support (Epinephrine)
2. No change in valve structure and function
3. Intact aorta

[**2148-12-9**] 04:44AM BLOOD WBC-11.0 RBC-3.17* Hgb-10.1* Hct-29.7*
MCV-94 MCH-31.8 MCHC-34.0 RDW-13.5 Plt Ct-247
[**2148-12-7**] 06:35AM BLOOD WBC-12.8* RBC-3.37* Hgb-10.7* Hct-31.4*
MCV-93 MCH-31.8 MCHC-34.2 RDW-14.9 Plt Ct-187
[**2148-12-6**] 03:09AM BLOOD PT-12.7 PTT-47.5* INR(PT)-1.1
[**2148-12-9**] 04:44AM BLOOD UreaN-13 Creat-0.4 Na-137 K-3.9 Cl-97
[**2148-12-8**] 06:00AM BLOOD UreaN-11 Creat-0.5 Na-137 K-4.3 Cl-99
[**2148-12-7**] 06:35AM BLOOD Glucose-102* UreaN-11 Creat-0.5 Na-134
K-4.8 Cl-100 HCO3-27 AnGap-12

Brief Hospital Course:
Catheterization revealed triple vessel disease and she was
referred for surrgery.  A CT scan of a pulmonary nodule was
obtained and the recommendation was for a 6month follow up.

Following a period of Plavix washout, the patient underwent
coronary artery bypass grafting x3 (Left internal mammary artery
graft to the left anterior descending, reverse saphenous vein
graft to the marginal branch and the posterior descending
artery) on [**12-5**] with Dr. [**Last Name (STitle) **].See operative note fro details.

Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably.  The patient was neurologically intact
and hemodynamically stable and had weaned from inotropic and
vasopressor support. She was transfused two units of blood for
post-operative anemia.  Plavix was given due to poor targets.
Beta blocker was initiated and the patient was gently diuresed
toward her preoperative weight.

The patient was transferred to the telemetry floor for further
recovery.  Chest tubes and pacing wires were discontinued
without complication.  She did have a brief burst of rapid
atrial fibrillation which responded to IV Lopressor. She had
recurrent atrial fibrillatin and was started on amiodarone and
maintained sinus rhythm susequently

The patient was evaluated by the Physical Therapy service for
assistance with strength and mobility.  By the time of discharge
on POD 7 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics.  The
patient was discharged home with VNA in good condition with
appropriate follow up instructions.


Medications on Admission:
- fish oil 1000 mcg daily
- MVI
- asa 81 mg daily
- atenolol 25 mg daily
- isosorbide dinitrite 10 mg tid
- simvastatin 10 mg daily
- ativan 1 mg daily

Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*11*
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
[**Last Name (STitle) **]:*50 Tablet(s)* Refills:*0*
5. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
[**Last Name (STitle) **]:*28 Tablet(s)* Refills:*0*
7. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two tablets (400mg) [**Hospital1 **] for two weeks, then one
tablet(200mg)[**Hospital1 **] for two weeks then one tablet (200mg) daily
until discontinued by your physician.
[**Name Initial (NameIs) **]:*120 Tablet(s)* Refills:*2*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 4 weeks.
[**Name Initial (NameIs) **]:*50 Tablet(s)* Refills:*0*
9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for fever or pain.
11. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
[**Name Initial (NameIs) **]:*90 Tablet(s)* Refills:*2*
12. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation QID (4 times a day).
[**Name Initial (NameIs) **]:*2 2* Refills:*6*
13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain and fever .


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Coronary Artery Disease
s/p Coronary Artery Bypass [**2148-12-5**]
chronic obstructive pulmonary disease
Hypertension
Hyperlipidemia
s/p Tonsillectomy


Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
leg:left leg incision- healing well, no erythema or drainage


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge


Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr.[**Last Name (STitle) **], [**First Name3 (LF) **] R. MD [**Telephone/Fax (1) 170**]   [**2149-1-8**] 1:00pm
and WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2148-12-17**] 10:45
in the [**Hospital **] medical office building [**Doctor First Name **] [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) **], [**1-1**] @ 10:20am

Please call to schedule the following:
Primary Care Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 38584**] [**Telephone/Fax (1) 3530**] in [**5-7**] weeks:
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Fax: [**Telephone/Fax (1) 6808**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**



Completed by:[**2148-12-12**]
{'Coronary atherosclerosis of native coronary artery,Acidosis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Intermediate coronary syndrome,Body Mass Index less than 19, adult,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Anxiety state, unspecified,Other specified diseases of blood and blood-forming organs,Anemia, unspecified,Peripheral vascular disease, unspecified'}


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: This 63 y/o female with pain radiating to both arms for 30 days,
improved with leaning forward. .
In ED, initial VS - HR: 76 BP: 137/80 O2 Sat: 98. CXR showed
findings c/w COPD/emphysema. Mid-to-lower thoracic spine
compression fracture.
No acute findings. EKG showed no STEMI, no ischemic changes.
Cardiac enzymes negative x 1.
.
Of note, patient failed prior stress test at [**Hospital1 102643**]
medical management failed to control chest pain. Per discussion
with atrius cardiology, admission to caridology for
consideration of cath. Patient was heparinized in the ED.
Unfortunately, further records not available at this time.
.

MEDICAL HISTORY: COPD
Hypertension
Hyperlipidemia
s/p Tonsillectomy

MEDICATION ON ADMISSION: - fish oil 1000 mcg daily
- MVI
- asa 81 mg daily
- atenolol 25 mg daily
- isosorbide dinitrite 10 mg tid
- simvastatin 10 mg daily
- ativan 1 mg daily

ALLERGIES: Penicillins / epinephrine / caffeine

PHYSICAL EXAM: On Admission:
VS - 99.5, 141/83, 76, 20, 98 RA
GENERAL - well-appearing female in NAD, comfortable, appropriate

FAMILY HISTORY: Mom - CVA
[**Name (NI) **] - triple bypass, DM

SOCIAL HISTORY: positive for tobacco, reports social EtOH, no drugs. Reports 1
ppd tobacco x 40 years. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acidosis,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Intermediate coronary syndrome,Body Mass Index less than 19, adult,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Anxiety state, unspecified,Other specified diseases of blood and blood-forming organs,Anemia, unspecified,Peripheral vascular disease, unspecified'}
