CHIEF COMPLAINT: chest pressure/pain

PRESENT ILLNESS: Ms. [**Known lastname 88403**] is 69 yo female with numerous cardiac risk factors
(HTN, HLD, smoking, +FHx) as well as AFib and SSS s/p pacemaker
who presented to [**Hospital3 1443**] ED this AM with chest
pressure. Symptoms started around 4am, when she woke up with
left-sided substernal chest pressure/tightness, non-radiating,
[**2177-2-27**] in severity. There was no associated shortness of breath,
nausea, vomiting or diaphoresis. When the pain did not go away,
she called the ambulance. In the ambulance she received NTG
SLx3, which made the pain resolve. In the ED, she was
hypertensive to >200 and started on NTG gtt for chest pain and
HTN. While on the NTG gtt, she reported L arm
discomfort/pressure and midsternal burning, which resolved with
uptitration of the drip. Initial EKG showed T wave changes in
aVL, but repeat EKG later in AM showed TWI in II,III,aVF, and
V3-V6. Labs significant for: Trop T <0.01, 0.35, 0.46 [ref range
0.01-0.04]; CK 59, 84, 87; MB 7, 7; MBI 8,8. D-dimer elevated to
0.61 so pt had V/Q scan which found low probability of PE.
Patient given ASA 325mg, Lopressor, morphine, Plavix loaded.
Prior to transfer to [**Hospital1 18**] for cath, she developed nausea which
was treated with Zofran.
.
On arrival to [**Hospital1 18**] CCU, patient is hemodynamically stable,
hypertensive to 160/100 on NTG gtt. She complains of persistent
nausea but denies chest pain, arm/jaw pain, shortness of breath,
or diaphoresis. EKG unchanged from prior. Labs show Trop T 0.39,
CK 85, MB 7.
.
Patient denies recent h/o anginal symptoms: no recent chest
pain, dyspnea on exertion, etc. She did have a similar episode
of chest pressure 2-3 years ago, for which she was worked up for
PE (CTA negative). She notes chronically decreased exercise
tolerance since getting her pacemaker 4 years ago. Per her
report, she had a nuclear stress test 3 months ago for health
maintenence purposes, which was completely normal.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.

MEDICAL HISTORY: -Paroxysmal AFib (on flecainide, off coumadin)
-SSS with pacemaker
-HTN
-HLD
-Hypothyroidism
-Raynaud's syndrome

MEDICATION ON ADMISSION: -ASA 325mg PO daily
-Simvastatin 20mg PO daily
-Metoprolol tartrate 100mg PO BID
-Flecainide 100mg PO BID
-Levothyroxine 100mcg PO daily
-Fish oil
-Vitamin C
-Calcium+D

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
GENERAL: pleasant F who appears uncomfortable [**1-28**] nausea, AAOx3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of CAD (age 58). Aunt with stroke. No known FHx HTN,
HLD, arrythmias, cardiomyopathies, sudden cardiac death.

SOCIAL HISTORY: Pt is retired lab worker. Divorced, lives alone at home. Former
smoker (1 pack/week, quit 25 years ago). Drinks ~1 bottle of
wine per week. Denies illicits.
Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atrial fibrillation,Unspecified acquired hypothyroidism,Raynaud's syndrome,Cardiac pacemaker in situ,Family history of ischemic heart disease
Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Atrial fibrillation,Hypothyroidism NOS,Raynaud's syndrome,Status cardiac pacemaker,Fam hx-ischem heart dis
Admission Date:  [**2179-2-3**]              Discharge Date:   [**2179-2-5**]

Date of Birth:  [**2109-6-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
chest pressure/pain

Major Surgical or Invasive Procedure:
cardiac catheterization

History of Present Illness:
Ms. [**Known lastname 88403**] is 69 yo female with numerous cardiac risk factors
(HTN, HLD, smoking, +FHx) as well as AFib and SSS s/p pacemaker
who presented to [**Hospital3 1443**] ED this AM with chest
pressure. Symptoms started around 4am, when she woke up with
left-sided substernal chest pressure/tightness, non-radiating,
[**2177-2-27**] in severity. There was no associated shortness of breath,
nausea, vomiting or diaphoresis. When the pain did not go away,
she called the ambulance. In the ambulance she received NTG
SLx3, which made the pain resolve. In the ED, she was
hypertensive to >200 and started on NTG gtt for chest pain and
HTN. While on the NTG gtt, she reported L arm
discomfort/pressure and midsternal burning, which resolved with
uptitration of the drip. Initial EKG showed T wave changes in
aVL, but repeat EKG later in AM showed TWI in II,III,aVF, and
V3-V6. Labs significant for: Trop T <0.01, 0.35, 0.46 [ref range
0.01-0.04]; CK 59, 84, 87; MB 7, 7; MBI 8,8. D-dimer elevated to
0.61 so pt had V/Q scan which found low probability of PE.
Patient given ASA 325mg, Lopressor, morphine, Plavix loaded.
Prior to transfer to [**Hospital1 18**] for cath, she developed nausea which
was treated with Zofran.
.
On arrival to [**Hospital1 18**] CCU, patient is hemodynamically stable,
hypertensive to 160/100 on NTG gtt. She complains of persistent
nausea but denies chest pain, arm/jaw pain, shortness of breath,
or diaphoresis. EKG unchanged from prior. Labs show Trop T 0.39,
CK 85, MB 7.
.
Patient denies recent h/o anginal symptoms: no recent chest
pain, dyspnea on exertion, etc. She did have a similar episode
of chest pressure 2-3 years ago, for which she was worked up for
PE (CTA negative). She notes chronically decreased exercise
tolerance since getting her pacemaker 4 years ago. Per her
report, she had a nuclear stress test 3 months ago for health
maintenence purposes, which was completely normal.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.

Past Medical History:
-Paroxysmal AFib (on flecainide, off coumadin)
-SSS with pacemaker
-HTN
-HLD
-Hypothyroidism
-Raynaud's syndrome


Social History:
Pt is retired lab worker. Divorced, lives alone at home. Former
smoker (1 pack/week, quit 25 years ago). Drinks ~1 bottle of
wine per week. Denies illicits.

Family History:
Mother died of CAD (age 58). Aunt with stroke. No known FHx HTN,
HLD, arrythmias, cardiomyopathies, sudden cardiac death.

Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: pleasant F who appears uncomfortable [**1-28**] nausea, AAOx3.
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 JVD of 3 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, 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 or rhonchi.
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.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM: unchanged from admission exam

Pertinent Results:
ADMISSION LABS:
WBC-6.5 RBC-3.55* Hgb-11.7* Hct-34.1* MCV-96 MCH-32.8* MCHC-34.2
RDW-12.1 Plt Ct-149*
PT-9.9 PTT-69.4* INR(PT)-0.9
Glucose-133* UreaN-18 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-26
AnGap-13
Calcium-8.9 Phos-3.3 Mg-2.2
ALT-37 AST-41*
.
CARDIAC ENZYMES:
[**2179-2-4**] 12:00 AM: CK (CPK) 85, MB 7, Trop T 0.39*
[**2179-2-4**] 06:07 AM: CK (CPK) 77, MB 6, Trop T 0.21*
.
ECHO ([**2179-2-4**]): The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.

IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
.
CHEST X-RAY ([**2179-2-4**]): Heart size is moderately enlarged.
Mediastinum is unremarkable. Lungs are essentially clear with no
pleural effusion and pneumothorax. There is no evidence of
pulmonary edema. Left-sided pacemaker is placed with two leads,
one of them terminating most likely in the right atrium and the
other one in the right ventricle. The right ventricle lead makes
a loop most likely within the posterolateral aspect
of the right atrium. No pneumothorax.

Brief Hospital Course:
# CHEST PAIN: Pt with multiple cardiac risk factors including
HTN, HLD, cigarettes and +FHx presenting with new-onset
substernal chest pressure. Symptoms improved with SL NTG and
resolved with initiation of NTG gtt + morphine bolus. Troponins
peaked at 0.46, CK 87, MB 7. Initial EKG without changes at OSH,
but repeat EKG showed TWI in II,III,aVF and V3-V6. Per OSH
records she was hypertensive to SBP>200 in the ED. Patient's
TIMI score was 5, putting her at 12% risk of death/MI at 2
weeks, and 26% risk of death/MI/urgent revascularization at 2
weeks. She was Plavix loaded and started on heparin gtt and NTG
gtt at OSH. Prior to cath, she was also treated with home
metoprolol tartrate 100mg PO BID (goal HR 60-70), atorvastatin
80mg PO daily, ASA 325mg PO daily, and Plavix 75mg PO daily, and
she was weaned off NTG gtt. She underwent cardiac cath on the
morning of [**2-4**], which showed mild CAD, LVEDP of 22, and anatomic
anomoly (bronchial arteries take off from RCA with AV
malformation). No interventions were performed. Patient did well
after cath, with no recurrence of chest pain or nausea. It was
felt that given that she had had SBP>200 at OSH, her chest pain
was most likely [**1-28**] hypertensive emergency. Therefore, on
discharge she was started on Lisinopril in addition to her home
Metoprolol for better control of blood pressure. She will also
continue her home dose of atorvastatin 40mg daily and ASA 325mg
daily. Patient agreed to purchase a BP cuff and monitor her
blood pressure regularly at home.
.
#.Nausea: patient c/o persistent nausea starting 2-3 hours prior
to arrival at [**Hospital1 18**] CCU. No evolving EKG changes or increasing
enzymes. Nausea most likely [**1-28**] morphine and NTG. Resolved with
zofran + ativan, and did not recur once NTG discontinued.
.
#.AFib: Per patient, she is no longer on Coumadin as her
cardiologist found that she only has paroxysmal afib. Her home
Flecainide was held in the setting of concern for NSTEMI; home
metoprolol and ASA were continued. Once NSTEMI had been ruled
out via cath, her home flecainide was restarted. Heart rate
well-controlled throughout hospitalization.
.
#.Sick Sinus Syndrome: patient has pacemaker, and is sinus paced
on EKG. Pacer interrogation was normal.
.
#.HTN: patient hypertensive to 160 on NTG gtt and home
metoprolol on arrival. Given that her chest pain was most likely
[**1-28**] hypertensive emergency ([**Last Name 788**] problem #1), she was discharged
on Lisinopril in addition to her home Metoprolol 100mg [**Hospital1 **].
.
#.HLD: patient on lipitor 20mg at home. She is discharged on
atorvastatin 40mg daily.
.
#.Hypothyroidism: continued home levothyroxine.
.
TRANSITION OF CARE:
1. Needs Chem 10 checked in 1 week because started Lisinopril
2. Please note RCA AVM found on cardiac cath.


Medications on Admission:
-ASA 325mg PO daily
-Simvastatin 20mg PO daily
-Metoprolol tartrate 100mg PO BID
-Flecainide 100mg PO BID
-Levothyroxine 100mcg PO daily
-Fish oil
-Vitamin C
-Calcium+D


Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day.

7. Outpatient Lab Work
Please check A1C and potassium on Tuesday [**2-9**] at 2:30p
at Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92136**] office


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Chest Pain
Hypertensive urgency
Hyperlipidemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You had chest pain that did not result in a heart attack. We are
not sure why you had chest pain but it might be because of high
blood pressure. An echocardiogram showed normal heart function
and a cardiac catheterization did not show any acute blockages.
We have started a new medicine to lower your blood pressure
further which is called lisinopril. This medicine can sometimes
raise your blood potassium level so we would like you to get
your potassium checked at Dr.[**Name (NI) 92137**] office next week. A
prescription was written for this, please bring it to your appt.

.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) **]
[**Hospital1 3597**] [**Numeric Identifier 20777**]
Phone: [**Telephone/Fax (3) 92138**] fax
Date/Time: please call the office on Monday for an appt
.
Name: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD
Specialty: Internal Medicine
When: Tuesday [**2-9**] at 2:30p
Address: [**Apartment Address(1) 92139**], [**Location (un) **],[**Numeric Identifier 92140**]
Phone: [**Telephone/Fax (1) 92141**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
{"Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atrial fibrillation,Unspecified acquired hypothyroidism,Raynaud's syndrome,Cardiac pacemaker in situ,Family history of ischemic heart disease"}


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 pressure/pain

PRESENT ILLNESS: Ms. [**Known lastname 88403**] is 69 yo female with numerous cardiac risk factors
(HTN, HLD, smoking, +FHx) as well as AFib and SSS s/p pacemaker
who presented to [**Hospital3 1443**] ED this AM with chest
pressure. Symptoms started around 4am, when she woke up with
left-sided substernal chest pressure/tightness, non-radiating,
[**2177-2-27**] in severity. There was no associated shortness of breath,
nausea, vomiting or diaphoresis. When the pain did not go away,
she called the ambulance. In the ambulance she received NTG
SLx3, which made the pain resolve. In the ED, she was
hypertensive to >200 and started on NTG gtt for chest pain and
HTN. While on the NTG gtt, she reported L arm
discomfort/pressure and midsternal burning, which resolved with
uptitration of the drip. Initial EKG showed T wave changes in
aVL, but repeat EKG later in AM showed TWI in II,III,aVF, and
V3-V6. Labs significant for: Trop T <0.01, 0.35, 0.46 [ref range
0.01-0.04]; CK 59, 84, 87; MB 7, 7; MBI 8,8. D-dimer elevated to
0.61 so pt had V/Q scan which found low probability of PE.
Patient given ASA 325mg, Lopressor, morphine, Plavix loaded.
Prior to transfer to [**Hospital1 18**] for cath, she developed nausea which
was treated with Zofran.
.
On arrival to [**Hospital1 18**] CCU, patient is hemodynamically stable,
hypertensive to 160/100 on NTG gtt. She complains of persistent
nausea but denies chest pain, arm/jaw pain, shortness of breath,
or diaphoresis. EKG unchanged from prior. Labs show Trop T 0.39,
CK 85, MB 7.
.
Patient denies recent h/o anginal symptoms: no recent chest
pain, dyspnea on exertion, etc. She did have a similar episode
of chest pressure 2-3 years ago, for which she was worked up for
PE (CTA negative). She notes chronically decreased exercise
tolerance since getting her pacemaker 4 years ago. Per her
report, she had a nuclear stress test 3 months ago for health
maintenence purposes, which was completely normal.
.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.

MEDICAL HISTORY: -Paroxysmal AFib (on flecainide, off coumadin)
-SSS with pacemaker
-HTN
-HLD
-Hypothyroidism
-Raynaud's syndrome

MEDICATION ON ADMISSION: -ASA 325mg PO daily
-Simvastatin 20mg PO daily
-Metoprolol tartrate 100mg PO BID
-Flecainide 100mg PO BID
-Levothyroxine 100mcg PO daily
-Fish oil
-Vitamin C
-Calcium+D

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
GENERAL: pleasant F who appears uncomfortable [**1-28**] nausea, AAOx3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: Mother died of CAD (age 58). Aunt with stroke. No known FHx HTN,
HLD, arrythmias, cardiomyopathies, sudden cardiac death.

SOCIAL HISTORY: Pt is retired lab worker. Divorced, lives alone at home. Former
smoker (1 pack/week, quit 25 years ago). Drinks ~1 bottle of
wine per week. Denies illicits. 

### Response:
{"Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Atrial fibrillation,Unspecified acquired hypothyroidism,Raynaud's syndrome,Cardiac pacemaker in situ,Family history of ischemic heart disease"}
