CHIEF COMPLAINT: NSTEMI

PRESENT ILLNESS: The pt is a 72y.o M with a PMH of CAD, AF, CRI now with NSTEMI.
Pt initally admitted to OSH with complaints of increased chest
discomfort at rest. Found to have NSTEMI with CK peak 362 CKMB
12-16% per report and Trop 2.33. Creatinine [**3-23**]. Being
transferred with plan for catheterization on Friday after
evaluation by renal team re: possible placement of dialysis
catheter for likely need of post cath dialysis.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: Isosorbide mononitrate 60mg [**Hospital1 **]
Omeprazole 20mg daily
ASA 81mg daily
Carvedilol 12.5mg [**Hospital1 **]
Loperarime 2mg [**Hospital1 **]
Warfarin 2.5mg daily
Lovastatin 20mg daily
Phoslo 667mg TIDWM
Ferrous sulfate 325mg TID
NTG prn
Epogen q other week prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.4 117/58 68 20 100,2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6cm. Bilat carotid bruits.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at LLSB, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. WWP. 2+ DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: 40 pack years, quit 10 years ago
-ETOH: None
-Illicit drugs: None
Subendocardial infarction, initial episode of care,End stage renal disease,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other and unspecified hyperlipidemia,Other symptoms involving cardiovascular system,Achalasia and cardiospasm,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Leukocytosis, unspecified,Disorders of phosphorus metabolism
Subendo infarct, initial,End stage renal disease,Chr systolic hrt failure,Hyp kid NOS w cr kid V,Crnry athrscl natve vssl,Atrial fibrillation,Hyperlipidemia NEC/NOS,Cardiovas sys symp NEC,Achalasia & cardiospasm,Ocl crtd art wo infrct,Leukocytosis NOS,Dis phosphorus metabol
Admission Date:  [**2147-2-22**]              Discharge Date:   [**2147-3-5**]

Date of Birth:  [**2074-4-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
NSTEMI

Major Surgical or Invasive Procedure:
Cardiac catheterization
Hemodialysis
Tunneled dialysis catheter placement


History of Present Illness:
The pt is a 72y.o M with a PMH of CAD, AF, CRI now with NSTEMI.
Pt initally admitted to OSH with complaints of increased chest
discomfort at rest. Found to have NSTEMI with CK peak 362 CKMB
12-16% per report and Trop 2.33. Creatinine [**3-23**]. Being
transferred with plan for catheterization on Friday after
evaluation by renal team re: possible placement of dialysis
catheter for likely need of post cath dialysis.

Pt previously admitted with angina [**4-24**] however had an ECG
without changes and had flat CE. Since cardiac catheterization
would be a high risk procedure in the setting of his chronic
renal nsufficiency, he was medically managed.

On review of systems, he denies any prior history of stroke,
TIA, 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 absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.

On arrival to the medical floor the patient reports [**4-26**] chest
tightness without radiation, similar to prior. Denies dyspnea,
nausea, diaphoresis.

Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension

2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS [**11/2141**]:
-->LMCA without disease
-->LAD with diffuse disease and vasospasm, reversed with TNG
-->D1: ulcerated 80% lesion
-->LCX: distal vasospasm, reversed with TNG
-->RCA: Severe diffuse disease with serial 90% lesions in the
PDA and 80% stenosis in the mid-RCA
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Acute myocardial infarction, secondary to severe LAD and LCx
coronary vasospasm. This was managed by intracoronary and
intravenous diltiazem and nitroglycerin therapies.

3. OTHER PAST MEDICAL HISTORY:
-Three vessel CAD: see above for details
-Perioperative (bowel resection) vasospasm requiring cardiac
cath with NTG
-Mild-moderate MR
[**Name13 (STitle) 37625**] EF: 45% with focal inferior-posterior wall motion
abnormalities
-Ischemic Colitis: s/p SMA thrombectomy, with [**Doctor Last Name 3379**] pouch
and end ileostomy. Also complicated by recent diversion colitis
in 2/[**2146**].
-Peripheral [**Year (4 digits) 1106**] disease s/p aortobifemoral bypass [**2131**]
-Raynauds
-Dementia
-Stage IV CKD: baseline creatinine appears to be around [**2-19**]
-Atrial fibrillation
-H/o perioperative CVA: no deficits
-Hyperlipidemia
-HTN
-H/o Achalasia s/p esophageal dilation
-H/o VRE infection

Social History:
-Tobacco history: 40 pack years, quit 10 years ago
-ETOH: None
-Illicit drugs: None

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
VS: 98.4 117/58 68 20 100,2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6cm. Bilat carotid bruits.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at LLSB, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. WWP. 2+ DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

Pertinent Results:
[**2147-2-22**] 10:40PM BLOOD WBC-8.3 RBC-3.38* Hgb-9.2* Hct-28.6*
MCV-85 MCH-27.3 MCHC-32.3 RDW-17.0* Plt Ct-238
[**2147-2-24**] 11:00AM BLOOD WBC-9.1 RBC-2.61* Hgb-7.4* Hct-22.1*
MCV-85 MCH-28.3 MCHC-33.4 RDW-16.6* Plt Ct-260
[**2147-2-24**] 11:22PM BLOOD Hct-33.1*#
[**2147-2-28**] 05:25AM BLOOD WBC-14.9* RBC-4.04* Hgb-11.4* Hct-34.2*
MCV-85 MCH-28.2 MCHC-33.3 RDW-17.8* Plt Ct-314
[**2147-3-5**] 04:52AM BLOOD WBC-12.7* RBC-3.58* Hgb-9.9* Hct-31.0*
MCV-87 MCH-27.6 MCHC-31.9 RDW-17.5* Plt Ct-228
[**2147-2-22**] 10:40PM BLOOD PT-24.2* PTT-36.3* INR(PT)-2.4*
[**2147-2-27**] 05:20AM BLOOD PT-15.7* PTT-73.3* INR(PT)-1.4*
[**2147-3-5**] 04:52AM BLOOD PT-21.4* PTT-35.0 INR(PT)-2.0*
[**2147-2-22**] 10:40PM BLOOD Glucose-108* UreaN-89* Creat-7.2*# Na-139
K-4.0 Cl-112* HCO3-15* AnGap-16
[**2147-3-5**] 04:52AM BLOOD Glucose-81 UreaN-28* Creat-4.9*# Na-134
K-4.9 Cl-97 HCO3-28 AnGap-14
[**2147-2-22**] 10:40PM BLOOD CK(CPK)-171
[**2147-3-4**] 12:15PM BLOOD CK(CPK)-69
[**2147-2-22**] 10:40PM BLOOD CK-MB-9 cTropnT-0.26*
[**2147-2-23**] 07:10AM BLOOD CK-MB-8 cTropnT-0.32*
[**2147-2-24**] 02:46PM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2147-2-25**] 05:56AM BLOOD CK-MB-NotDone cTropnT-0.68*
[**2147-3-4**] 12:15PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2147-2-25**] 05:56AM BLOOD calTIBC-281 Ferritn-74 TRF-216
[**2147-2-23**] 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2147-2-23**] 07:10AM BLOOD HCV Ab-NEGATIVE
[**2147-3-4**] 02:41PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2147-3-4**] 02:41PM URINE Blood-SM  Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2147-3-4**] 02:41PM URINE RBC-<1 WBC-4 Bacteri-FEW Yeast-NONE
Epi-<1

TTE ([**2-23**]): The left atrium is elongated. Mild regional left
ventricular systolic dysfunction with mid inferolateral wall to
distal inferior wall akinesis. LVEF 50-55%. [**11-18**]+ MR. Mild
pulmonary artery systolic hypertension.

Carotid U/S ([**2-23**]):
1. Calcified plaque with 40-59% stenosis of the right internal
carotid
artery.
2. Calcified plaque with less than 40% stenosis of the left
internal carotid artery.

Cardiac cath ([**2-24**]):
1.  Selective coronary angiography of this co-dominant system
demonstrated severe three vessel coronary artery disease.  The
LMCA had no angiographically apparent disease.  The LAD had a
70% very distal to
apical disease.  There was an 80% diffuse stenosis in a small to
medium
1st diagonal branch.  The LCX had a second OM with a 90%
stenosis and a
TO in the OM3.  There was insignificant plaquing in the large L
posterolateral branch.  The RCA had an 80% distal stenosis and a
diffuse
60-70% stenosis in a small PDA.
2.  Resting hemodynamics revealed elevated right and left
ventricular
enddiastolic filling pressures at 13 and 16 mmHg.  The mean PA
pressure
was 23 mmHg (phasic 35/13 mmHg).  The PCWP was 16 mmHg.  The
cardiac
index was 3.5 L/min/m2.  The mean systemic arterial pressure was
91
(161/56 mmHg).
4. Successful PTCA and stenting of the RCA with a 3.0x18mm
Vision stent.
Final angiography revealed no residual stenosis, no
angiographically
apparent dissection and TIMI III flow (See PTCA comments).
4. Successful PTCA and stenting of the OM2 with a 2.0x23mm Mini
Vision
stent. Fianl angiography revealed no residual stenosis, no
angiographically apparent dissection and TIMI III flow (See PTCA

comments).
5. Unsuccessful attempt to PTCA of the small 1st diagonal
branch.

Brief Hospital Course:
1. NSTEMI: His cardiac markers trended down at [**Hospital1 18**]. He was
initially started on heparin and nitroglycerin drips, and
continued on ASA, clopidogrel, carvedilol, and statin. Echo
showed new akinesis of inferior/inferolateral walls, although
preserved EF. He went to cardiac cath, where he had stenting of
RCA and OM2. He was transferred to the CCU afterwards for HTN.
He was initially controlled with nitroprusside and nitroglycerin
gtt. Upon arrival to CCU patient was only on nitroglycerin gtt
and this was quickly weaned off. He had slightly higher BPs in
the morning and was started on captopril, later changed to
lisinopril. CK and CKMB were followed and trended down. He was
subsequently asymptomatic except for an episode of CP with
dynamic ST depressions after an HD session, resolved with NTG
SL, cardiac markers flat. His isosorbide dose was increased from
10mg TID to 30mg TID and he had no further symptoms.

2. End-stage renal disease: Patient's outpatient nephrologist
felt he was ready to begin HD. He received acetylcysteine 1200mg
PO BID x4 doses as well as bicarb hydration prior to/after
cardiac cath for renal protection, but HD was still deemed
necessary. He received HD initially in the CCU via a temporary
catheter. He later had a right chest tunneled catheter placed
and underwent Tu/Th/Sat HD via this. He noted some intermittent
extremity cramping, associated with fasciculations on exam, felt
related to his newly started dialysis. These improved during the
admission. He was also continued on Ca acetate, started on
sevelamer, and received iron at HD. Hepatitis serology and PPD
were negative.

3. Atrial Fibrillation: Remained in sinus rhythm during this
admission. Initially on heparin alone with warfarin held for his
tunneled catheter placement. After this, warfarin was restarted
and bridged with heparin until his INR was therapeutic. His
warfarin dose was increased from 2.5mg to 5mg daily to achieve
this, and will be checked at his outpatient lab 2 days after
discharge.

4. Hypertension: BP was intially elevated and managed in the CCU
as above. On the floor, he had further HTN that improved with
his HD sessions. He was discharged normotensive on lisinopril
and carvedilol.

5. Anemia: Early in admission, his hematocrit trended down to
22.1 with no evidence of active bleeding. He was transfused two
units pRBCs with ~10 point improvement in hematocrit, which
remained stable.

6. Bruits: Had carotid and abdominal bruits on exam. Carotid U/S
obtained showed noncritical ICA stenosis. Review of CT abdomen
from last year showed significant aortic calcifications, stable
from prior study, which was felt to be the cause of his
abdominal bruit.

Medications on Admission:
Isosorbide mononitrate 60mg [**Hospital1 **]
Omeprazole 20mg daily
ASA 81mg daily
Carvedilol 12.5mg [**Hospital1 **]
Loperarime 2mg [**Hospital1 **]
Warfarin 2.5mg daily
Lovastatin 20mg daily
Phoslo 667mg TIDWM
Ferrous sulfate 325mg TID
NTG prn
Epogen q other week prn

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Loperamide 2 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
4. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as needed.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO three
times a day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. 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*
13. Isosorbide Dinitrate 30 mg Tablet Sig: One (1) Tablet PO
three times a day: on dialysis days, give after HD.
Disp:*90 Tablet(s)* Refills:*2*

Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary:
Non ST-elevation myocardial infarction
End stage renal disease

Secondary:
Hypertension
Chronic systolic heart failure
Atrial fibrillation


Discharge Condition:
Stable


Discharge Instructions:
You were admitted to [**Hospital1 18**] after having a small heart attack.
You had two stents placed in your coronary arteries (that supply
the heart muscle) and your heart pumping function remains good.
You were also started on dialysis for your kidney failure and
received 2 units of blood for anemia (low red blood cells).

Please go to all follow up appointments and take all medications
as prescribed. We have made the following medication changes:
1. Increase aspirin to 325mg daily for one month, then you may
resume the 81mg daily dose.
2. Take clopdiogrel daily for one month to prevent clots in your
stents.
3. Decreased your isosorbide MONOnitrate to isosorbide DInitrate
30mg three times daily.
4. Decreased your carvedilol to 6.25mg twice daily.
5. Increased your calcium acetate (Phoslo) to 2 tabs three times
daily.
6. Started sevelamer, which helps prevent phosphate from
becoming too high.
7. Stopped your oral iron (you will get this at dialysis).
8. Started nephrocaps, a vitamin for patients with kidney
damage.
9. Started lisinopril, a blood pressure medicine that also helps
the heart.
10. Changed omeprazole to pantoprazole, as this is less likely
to interact with your heart medications.
11. Increased warfarin to 5mg daily as your blood test (INR) was
not high enough on 2.5mg daily.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere
to 2 gm sodium diet.

If you experience chest pain or pressure, trouble breathing,
fevers, chills, palpitations, lightheadedness, dizziness, or any
other concerning symptoms, please seek medical attention or come
to the ER immediately.

Followup Instructions:
Please go to your regular laboratory on Tuesday [**3-7**] to have an
INR drawn to check if your warfarin dose is appropriate. Have
the results faxed to Dr. [**Last Name (STitle) 30176**] at [**Telephone/Fax (1) 93989**]. If this can
be done at dialysis instead, that would be acceptable.

You will have dialysis on Tuesday, Thursday, and Saturday at
[**Location (un) **] Dialysis Center.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2147-3-13**] 11:00

Please follow up with your primary care doctor, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30176**],
on Thursday [**4-6**] at 10:00 am. Phone: [**Telephone/Fax (1) 30242**].

Please follow up with your cardiologist, [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 8579**], on [**4-3**] at 9:00 am. Phone: [**Telephone/Fax (1) 23882**]



Completed by:[**2147-3-6**]
{'Subendocardial infarction, initial episode of care,End stage renal disease,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other and unspecified hyperlipidemia,Other symptoms involving cardiovascular system,Achalasia and cardiospasm,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Leukocytosis, unspecified,Disorders of phosphorus metabolism'}


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: NSTEMI

PRESENT ILLNESS: The pt is a 72y.o M with a PMH of CAD, AF, CRI now with NSTEMI.
Pt initally admitted to OSH with complaints of increased chest
discomfort at rest. Found to have NSTEMI with CK peak 362 CKMB
12-16% per report and Trop 2.33. Creatinine [**3-23**]. Being
transferred with plan for catheterization on Friday after
evaluation by renal team re: possible placement of dialysis
catheter for likely need of post cath dialysis.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension

MEDICATION ON ADMISSION: Isosorbide mononitrate 60mg [**Hospital1 **]
Omeprazole 20mg daily
ASA 81mg daily
Carvedilol 12.5mg [**Hospital1 **]
Loperarime 2mg [**Hospital1 **]
Warfarin 2.5mg daily
Lovastatin 20mg daily
Phoslo 667mg TIDWM
Ferrous sulfate 325mg TID
NTG prn
Epogen q other week prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.4 117/58 68 20 100,2L
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6cm. Bilat carotid bruits.
CARDIAC: RRR, normal S1, S2. 2/6 systolic murmur at LLSB, no
rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: NABS. Soft, NTND.
EXTREMITIES: No edema. WWP. 2+ DP pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: -Tobacco history: 40 pack years, quit 10 years ago
-ETOH: None
-Illicit drugs: None 

### Response:
{'Subendocardial infarction, initial episode of care,End stage renal disease,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other and unspecified hyperlipidemia,Other symptoms involving cardiovascular system,Achalasia and cardiospasm,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Leukocytosis, unspecified,Disorders of phosphorus metabolism'}
