CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 71 yo M with HLD and prior CVA presents to his PCP's office with
a two week hx of intermittent SSCP usually occuring exertion and
alleviated by rest. No significant associated SOB, nausea, or
diaphoresis.  Fleeting CP at rest, but never sustained.
Presented to PCP today [**Name Initial (PRE) **]/c it had been getting worse for the
past 2 days, occuring with minimal exertion. PCP referred him to
the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where initial evaluation demonstrates non-specific
STT changes without prior for comparison and troponin I of 0.16.
.
According to ED physician note, he was ordered for ASA 325,
plavix load, heparin drip, lipitor, and metoprolol.  He arrived
on a heparin drip without any documentation that the other
medications had actually been given. Pt recalls getting only
aspirin 325 and ativan.  I spoke to nurse mgr at [**Hospital1 **] who
could not find [**Month (only) 16**], and stated that she could not say for
certain that he had been given plavix. CXR at [**Hospital1 **] reportedly
unremarkable.
.
On arrival to [**Hospital Ward Name 121**] 3, EKG was notable for leftward axis and
prolonged QT~500ms. Pt was without any complaints. Denied
CP/SOB/NAUSEA.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia + Family Hx
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- GERD, BARRETT'S
- MIGRAINE HA
- CVA
- BPH
- HLD

MEDICATION ON ADMISSION: celexa 40mg daily
atorvastatin 20mg daily
nexium 40mg daily
xanax 0.25 prn
flonase
nortryptiline 150mg qhs (does not take every night)
fiorecet prn
ASA 81mg

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.7 BP=134/74 HR=58 RR=14 O2 sat=98%ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Multiple family members with CAD, no hx SCD

SOCIAL HISTORY: -Tobacco history: distant 40+ pkyr hx
-ETOH: quit many years ago, denied alcoholism
-Illicit drugs: never
-Retired [**Company 2318**] maintenance technician, lives with wife, both
independent
Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Other and unspecified hyperlipidemia,Barrett's esophagus,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysthymic disorder,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Family history of ischemic heart disease,Long-term (current) use of aspirin
Subendo infarct, initial,Ac posthemorrhag anemia,Crnry athrscl natve vssl,Iatrogenc hypotnsion NEC,Hyperlipidemia NEC/NOS,Barrett's esophagus,BPH w/o urinary obs/LUTS,Dysthymic disorder,Hypertension NOS,Migrne unsp wo ntrc mgrn,Hx TIA/stroke w/o resid,History of tobacco use,Fam hx-ischem heart dis,Long-term use of aspirin
Admission Date:  [**2102-2-17**]              Discharge Date:   [**2102-2-26**]

Date of Birth:  [**2030-9-2**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
Cardiac Catheterization

History of Present Illness:
71 yo M with HLD and prior CVA presents to his PCP's office with
a two week hx of intermittent SSCP usually occuring exertion and
alleviated by rest. No significant associated SOB, nausea, or
diaphoresis.  Fleeting CP at rest, but never sustained.
Presented to PCP today [**Name Initial (PRE) **]/c it had been getting worse for the
past 2 days, occuring with minimal exertion. PCP referred him to
the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where initial evaluation demonstrates non-specific
STT changes without prior for comparison and troponin I of 0.16.
.
According to ED physician note, he was ordered for ASA 325,
plavix load, heparin drip, lipitor, and metoprolol.  He arrived
on a heparin drip without any documentation that the other
medications had actually been given. Pt recalls getting only
aspirin 325 and ativan.  I spoke to nurse mgr at [**Hospital1 **] who
could not find [**Month (only) 16**], and stated that she could not say for
certain that he had been given plavix. CXR at [**Hospital1 **] reportedly
unremarkable.
.
On arrival to [**Hospital Ward Name 121**] 3, EKG was notable for leftward axis and
prolonged QT~500ms. Pt was without any complaints. Denied
CP/SOB/NAUSEA.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.


Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia + Family Hx
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- GERD, BARRETT'S
- MIGRAINE HA
- CVA
- BPH
- HLD


Social History:
-Tobacco history: distant 40+ pkyr hx
-ETOH: quit many years ago, denied alcoholism
-Illicit drugs: never
-Retired [**Company 2318**] maintenance technician, lives with wife, both
independent


Family History:
Multiple family members with CAD, no hx SCD


Physical Exam:
VS: T=97.7 BP=134/74 HR=58 RR=14 O2 sat=98%ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with no appreciable JVP at 90 degrees.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes. DIFFUSE RONCHI CLEARED W/ COUGHING.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+  DP 2+ PT 2+
Left:  Carotid 2+  DP 2+ PT 2+


Pertinent Results:
ADMISSION LABS:

[**2102-2-17**] 06:30PM   ALT(SGPT)-20 AST(SGOT)-32 ALK PHOS-65
AMYLASE-49 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4
[**2102-2-17**] 06:30PM   ALBUMIN-3.7 CALCIUM-8.0* CHOLEST-140
[**2102-2-17**] 06:30PM   VIT B12-423
[**2102-2-17**] 06:30PM   %HbA1c-6.0* eAG-126*
[**2102-2-17**] 06:30PM   WBC-3.9* RBC-3.57* HGB-12.5* HCT-33.9* MCV-95
MCH-34.9* MCHC-36.8* RDW-12.8
[**2102-2-17**] 06:30PM   NEUTS-49.5* LYMPHS-39.8 MONOS-8.3 EOS-1.9
BASOS-0.4
[**2102-2-17**] 06:30PM   PLT COUNT-255
[**2102-2-17**] 06:30PM   PT-13.6* PTT-25.9 INR(PT)-1.2*
[**2102-2-17**] 02:10AM   GLUCOSE-105* UREA N-11 CREAT-1.1 SODIUM-138
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-28 ANION GAP-10
[**2102-2-17**] 02:10AM   CK(CPK)-217
[**2102-2-17**] 02:10AM   CK-MB-7 cTropnT-0.45*
[**2102-2-17**] 02:10AM   CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-2.5
[**2102-2-17**] 02:10AM   WBC-6.0 RBC-3.86* HGB-12.7* HCT-35.6* MCV-92
MCH-32.9* MCHC-35.7* RDW-12.9
[**2102-2-17**] 02:10AM   PLT COUNT-281
[**2102-2-17**] 02:10AM   PT-13.2 PTT-26.5 INR(PT)-1.1

Cath [**2-17**]:
1. Selective coronary angiography in this right dominant system
revealed
three vessel heavily calcified coronary artery disease with
diffuse slow
flow consistent with microvascular dysfunction.  The LMCA is
heavily
calcified with mild distal tapering.  The LAD is heavily
calcified with
a high take off D1 with near origin 50% stenosis.  The proximal
LAD is
calcified with a hazy 70% stenosis at S1.  There is a mid 50%
stenosis
after S2 followed by a 40% stenosis at D2.  There is mid diffuse
disease
to 40-50%.  D2 has a proximal 75% stenosis.  The distal LAD is
calcified
70% stenosis with TIMI 2 flow; apical 60% stenosis.  The LCx is
heavily
calcified with near ostial calcified 80% stenosis involving a
small OM1;
[rpxo,a; 70% stenosis involving OM2.  There is 60% stenosis in
the
proximal OM2 with pulsatile distal flow.  The mid AV groove Cx
has 50%
stenosis with slow flow into small OM3, OM4/LPL1, LPL2, and
terminal AV
groove Cx.  The RCA is heavily calcified with proximal 90%
stenosis, mid
diffuse 50% stenosis, diffuse disease distally.  There is distal
80%
stenosis before RPDA, a small RPL1, and the apical inferior
septum is
supplied by AM.  There is slow flow consistent with
microvascular
dysfunction.  The mid RCA supplies the atrial branch.
2. Limited resting hemodynamics revealed normal left sided
filling
pressures with LVEDP 8 mmHg.  There is moderately elevated
systemic
arterial pressures with central aortic pressure 162/74 with a
mean of 92
mmHg.

FINAL DIAGNOSIS:
1. Three vessel heavily calcified coronary artery disease with
diffuse
slow flow consistent with microvascular dysfunction.
2. Systemic systolic arterial hypertension.
3. Normal LV systolic and diastolic function.

CXR [**2-18**]:
FINDINGS: There are no old films available for comparison. The
lungs are
clear without infiltrate or effusion. There are mild
degenerative changes of
the thoracic spine with endplate sclerosis and flowing anterior
osteophytes.
The heart is upper limits normal in size. The lungs are clear
without an
infiltrate or effusion.


Brief Hospital Course:
71M with no PMH of CAD but with multiple risk factors presented
to [**Hospital1 18**] as a transfer for the complaint of substernal chest
pain, NSTEMI.

# Acute Coronary Syndrome/NSTEMI: His 2 week long hx of new
exertional CP and positive troponin suggested plaque
instability.
- Cath on [**2-17**] showed heavily calcified multivessel disease
- Evaluated by CSURG, who deemed the patient was a candidate for
CABG
- Continued ASA 325 daily
- Continued on heparin drip in the post cath period
- Lipitor 80mg daily
.
# Long QT: QTc in the 500's, asymptomatic, no events on tele
during admission
- discontinued noritryptiline.

Transfered to cardiolgy for surgery:

The patient was brought to the operating room on [**2-21**] where the
patient underwent CABG x4(LIMA-LAD,SVG-OM1,SVG-OM2,SVG-dRCA).

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, weaned from inotropic and
vasopressor support.  Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight.

The patient was transferred to the telemetry floor for further
recovery.  Chest tubes and pacing wires were discontinued
without complication.  The patient was evaluated by the physical
therapy service for assistance with strength and mobility.

By the time of discharge on POD 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics.  The patient was discharged to a rehab in good
condition with appropriate follow up instructions.


Medications on Admission:
celexa 40mg daily
atorvastatin 20mg daily
nexium 40mg daily
xanax 0.25 prn
flonase
nortryptiline 150mg qhs (does not take every night)
fiorecet prn
ASA 81mg


Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
const.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
10. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
14. potassium chloride 20 mEq Packet Sig: One (1)  PO twice a
day for 7 days.
15. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day:
prn for anxiety.
16. INSULIN SS
Sliding Scale

Fingerstick QACHS

Insulin SC Sliding Scale

Breakfast Lunch Dinner Bedtime

Humalog

Glucose Insulin Dose

71-109    mg/dL 0   Units 0   Units 0   Units 0   Units
110-140   mg/dL 2   Units 2   Units 2   Units 0   Units
141-180   mg/dL 4   Units 4   Units 4   Units 2   Units
181-210   mg/dL 6   Units 6   Units 6   Units 4   Units
211-240   mg/dL 8   Units 8   Units 8   Units 6   Units
> 240     mg/dL Notify M.D.


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]

Discharge Diagnosis:
Chest pain, CAD

Hyperlipidemia
GERD
Barrett's Esophagus
BPH
Depression
Anxiety

Discharge Condition:
DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal 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:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2102-3-16**] 1:30

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2102-3-31**] 9:00

Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 4475**]
in [**4-11**] weeks

**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:[**2102-2-26**]
{"Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Other and unspecified hyperlipidemia,Barrett's esophagus,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysthymic disorder,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Family history of ischemic heart disease,Long-term (current) use of aspirin"}


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: 71 yo M with HLD and prior CVA presents to his PCP's office with
a two week hx of intermittent SSCP usually occuring exertion and
alleviated by rest. No significant associated SOB, nausea, or
diaphoresis.  Fleeting CP at rest, but never sustained.
Presented to PCP today [**Name Initial (PRE) **]/c it had been getting worse for the
past 2 days, occuring with minimal exertion. PCP referred him to
the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where initial evaluation demonstrates non-specific
STT changes without prior for comparison and troponin I of 0.16.
.
According to ED physician note, he was ordered for ASA 325,
plavix load, heparin drip, lipitor, and metoprolol.  He arrived
on a heparin drip without any documentation that the other
medications had actually been given. Pt recalls getting only
aspirin 325 and ativan.  I spoke to nurse mgr at [**Hospital1 **] who
could not find [**Month (only) 16**], and stated that she could not say for
certain that he had been given plavix. CXR at [**Hospital1 **] reportedly
unremarkable.
.
On arrival to [**Hospital Ward Name 121**] 3, EKG was notable for leftward axis and
prolonged QT~500ms. Pt was without any complaints. Denied
CP/SOB/NAUSEA.
.
On review of systems, he denies any prior history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia + Family Hx
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- GERD, BARRETT'S
- MIGRAINE HA
- CVA
- BPH
- HLD

MEDICATION ON ADMISSION: celexa 40mg daily
atorvastatin 20mg daily
nexium 40mg daily
xanax 0.25 prn
flonase
nortryptiline 150mg qhs (does not take every night)
fiorecet prn
ASA 81mg

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.7 BP=134/74 HR=58 RR=14 O2 sat=98%ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Multiple family members with CAD, no hx SCD

SOCIAL HISTORY: -Tobacco history: distant 40+ pkyr hx
-ETOH: quit many years ago, denied alcoholism
-Illicit drugs: never
-Retired [**Company 2318**] maintenance technician, lives with wife, both
independent 

### Response:
{"Subendocardial infarction, initial episode of care,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Other and unspecified hyperlipidemia,Barrett's esophagus,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dysthymic disorder,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Personal history of tobacco use,Family history of ischemic heart disease,Long-term (current) use of aspirin"}
