CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 65 year old male w/ PmHx of HTN and longstanding GERD (s/p
Nissen procedure) who presented to OSH with chest pain and found
to have elevated troponin without EKG changes, diagnosed with
NSTEMI and transfered to [**Hospital1 18**] for further evaluation.
Mr. [**Known lastname 73466**] reports that around 10am in the morning he developed
a pressure-like sensation around his sternum. He has prominent
GERD symptoms chronically and takes [**Hospital1 **] omeprazole, but this
felt different than his GERD symptoms and didn't feel like
anything he's ever had before. He devleoped diaphoresis, SOB,
and nausea with dry heaving shortly after the chest discomfort
started. He went to [**Hospital3 **] around 2pm. Initial EKG
showed no ischemic changes but troponin I there was elevated at
3.54. He was given 325mg ASA, 75mg clopidogrel, 2SL nitro, nitro
past, 4mg IV morphine, and 40mg simvastatin. Cardiology at
[**Hospital1 2436**] recommended transfer to [**Hospital1 18**].
On arrival to the [**Hospital1 18**] ED, inital VS: 97.4 67 147/107 18 100%
2L. EKG showed no ischemic changes. Guiac negative and started
on heparin gtt for troponin of 0.47 with CK 144 and CKMB 16.
Since chest pain was still present, was given 5mg IV morphine.
He was chest pain free at transfer to [**Hospital Ward Name 121**] 2 with Vs at transfer
97.8, 71, 162/90, 16, 99%RA.

MEDICAL HISTORY: Hiatal hernia, Nissen fundoplication [**2105-7-16**]
GERD
s/p ACL repair in [**2099**]
HTN
Depression
Peroneal nerve entrapemnt s/p surgical decompression in [**2102**]
B/l inguinal hernia repair in [**2102**]
Anemia
R should rotator cuff tear and biceps tendon tear in [**1-28**]

MEDICATION ON ADMISSION: Lisinopril 20mg PO daily
Omeprazole 40mg PO BID
Fluoxetine 40mg PO daily
ASA 81mg PO daily

ALLERGIES: Codeine / Amoxicillin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - Temp 98.0F, BP 166/99, HR 77, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal deficits, intact sensation in
both LE without areas of numbness or paresthesias
BACK: mild pain to palpation over lower back and left SI joint
.
DISCHARGE PHYSICAL EXAM
VS Tmax 99.5, BP 110-140s/68-96, HR 60s, RR18, sats 100% RA
unchanged

FAMILY HISTORY: Father died of MI at age 70, mother and siblings are healthy

SOCIAL HISTORY: Wroked as a painter, physically active. Divorced, in a
monogamous relationship with girlfriend. [**Name (NI) 1139**] - greater than
30 pack years, quit in [**2088**], began smoking at age 12. Alcohol -
1-2 drinks beer daily, almost never binge drinks. No illicit/IV
drug use.
Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Sciatica,Depressive disorder, not elsewhere classified
Subendo infarct, initial,Crnry athrscl natve vssl,Hypertension NOS,Esophageal reflux,Sciatica,Depressive disorder NEC
Admission Date:  [**2108-2-13**]              Discharge Date:   [**2108-2-15**]

Date of Birth:  [**2042-10-15**]             Sex:   M

Service: MEDICINE

Allergies:
Codeine / Amoxicillin

Attending:[**First Name3 (LF) 2891**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
[**2108-2-14**] left heart catheterization with bare metal stent placed
in left circumflex


History of Present Illness:
65 year old male w/ PmHx of HTN and longstanding GERD (s/p
Nissen procedure) who presented to OSH with chest pain and found
to have elevated troponin without EKG changes, diagnosed with
NSTEMI and transfered to [**Hospital1 18**] for further evaluation.
Mr. [**Known lastname 73466**] reports that around 10am in the morning he developed
a pressure-like sensation around his sternum. He has prominent
GERD symptoms chronically and takes [**Hospital1 **] omeprazole, but this
felt different than his GERD symptoms and didn't feel like
anything he's ever had before. He devleoped diaphoresis, SOB,
and nausea with dry heaving shortly after the chest discomfort
started. He went to [**Hospital3 **] around 2pm. Initial EKG
showed no ischemic changes but troponin I there was elevated at
3.54. He was given 325mg ASA, 75mg clopidogrel, 2SL nitro, nitro
past, 4mg IV morphine, and 40mg simvastatin. Cardiology at
[**Hospital1 2436**] recommended transfer to [**Hospital1 18**].
On arrival to the [**Hospital1 18**] ED, inital VS: 97.4 67 147/107 18 100%
2L. EKG showed no ischemic changes. Guiac negative and started
on heparin gtt for troponin of 0.47 with CK 144 and CKMB 16.
Since chest pain was still present, was given 5mg IV morphine.
He was chest pain free at transfer to [**Hospital Ward Name 121**] 2 with Vs at transfer
97.8, 71, 162/90, 16, 99%RA.

Currently, symptom free. Only other thing that has been going on
recently is severe lower back/Left SI pain with radiation down
the left leg which got much worse over weekend. Started having
issues with this after hurting his back lifting furniture a few
months back. Has received steroid injections in his back in the
past. Over weekend got so bad his feet became a bit numb and
that he couldn't walk much, but this has resolved. Is in process
of being evaluated by a spinal surgeon for this issue. Also
reports intermittent diarrhea with food for many months.

REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.

Past Medical History:
Hiatal hernia, Nissen fundoplication [**2105-7-16**]
GERD
s/p ACL repair in [**2099**]
HTN
Depression
Peroneal nerve entrapemnt s/p surgical decompression in [**2102**]
B/l inguinal hernia repair in [**2102**]
Anemia
R should rotator cuff tear and biceps tendon tear in [**1-28**]

Social History:
Wroked as a painter, physically active. Divorced, in a
monogamous relationship with girlfriend. [**Name (NI) 1139**] - greater than
30 pack years, quit in [**2088**], began smoking at age 12. Alcohol -
1-2 drinks beer daily, almost never binge drinks. No illicit/IV
drug use.


Family History:
Father died of MI at age 70, mother and siblings are healthy

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.0F, BP 166/99, HR 77, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal deficits, intact sensation in
both LE without areas of numbness or paresthesias
BACK: mild pain to palpation over lower back and left SI joint
.
DISCHARGE PHYSICAL EXAM
VS Tmax 99.5, BP 110-140s/68-96, HR 60s, RR18, sats 100% RA
unchanged

Pertinent Results:
ADMISSION LABS
[**2108-2-13**] 09:50PM BLOOD WBC-6.8 RBC-3.85* Hgb-11.9* Hct-38.6*
MCV-100* MCH-31.1 MCHC-30.9* RDW-11.8 Plt Ct-415
[**2108-2-13**] 09:50PM BLOOD Neuts-87.9* Lymphs-8.8* Monos-2.6 Eos-0.7
Baso-0
[**2108-2-13**] 09:50PM BLOOD PT-10.9 PTT-31.4 INR(PT)-1.0
[**2108-2-13**] 09:50PM BLOOD Glucose-132* UreaN-21* Creat-1.0 Na-132*
K-4.7 Cl-99 HCO3-21* AnGap-17
[**2108-2-14**] 07:20AM BLOOD Calcium-8.9 Phos-2.1* Mg-2.0
.
CARDIAC ENZYMES
[**2108-2-13**] 09:50PM BLOOD CK-MB-16* MB Indx-11.1*
[**2108-2-13**] 09:50PM BLOOD cTropnT-0.47*
[**2108-2-14**] 07:20AM BLOOD CK-MB-11* MB Indx-9.7* cTropnT-0.49*
.
DISCHARGE LABS
[**2108-2-14**] 07:20AM BLOOD WBC-7.1 RBC-3.53* Hgb-11.3* Hct-34.4*
MCV-98 MCH-32.0 MCHC-32.8 RDW-12.1 Plt Ct-322
[**2108-2-15**] 06:30AM BLOOD UreaN-8 Creat-0.9 Na-136 K-4.3 Cl-100
[**2108-2-15**] 06:30AM BLOOD ALT-42* AST-65* AlkPhos-47 TotBili-0.9
[**2108-2-15**] 06:30AM BLOOD Triglyc-241* HDL-70 CHOL/HD-2.7
LDLcalc-71
.
IMAGES
[**2108-2-14**] CARDIAC CATH: COMMENTS:
1) Selective coronary angiography of this right-dominant system
demonstrated two-vessel coronary artery disease.  The LMCA and
LAD had
no angiographically-apparent flow-limiting stenoses.  The large
OM
branch of the LCx had a 70% stenosis at the bifurcation.  The
proximal
RCA had a 50-60% stenoses.
2)
3) Limited resting hemodynamics revealed systemic arterial
normotension,
with a central aortic pressure of 127/78 mmHg.

FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Successful BMS to LCx.
3. Aspirin 81 mg daily indefinitely and clopidogrel 75 mg daily
for 1
month minimum, longer if no bleeding.
.
3/38/12 TTE: RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated
RA.

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%). Doppler parameters are indeterminate for LV diastolic
function. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Trivial MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR. Normal PA systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. 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: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild mitral regurgitation.
.


Brief Hospital Course:
Mr. [**Known lastname 73466**] is a 65 year old male w/ hypertension (HTN) and
difficult to control GERD (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1358**]) who presented to OSH with
chest pain different from his baseline GERD and found to have
elevated troponin without EKG changes ruling in for NSTEMI and
transfered to [**Hospital1 18**].
.
# Non-ST elevation myocardial infarction (NSTEMI): His chest
pain syndrome was very different from his baseline GERD with a
substernal location, pressure-like pain, and associated
diaphoresis and nausea.  Eventually, he became chest pain free
and without shortness of breath, but took hours to achieve this
with morphine and nitro. No heart failure on symptoms or exam.
No prior history of coronary disease nor stable anginal syndrome
and no prior caths but has smoking history and hypertension.  He
recieved aspirin 325 mg, clopidogrel loaded 600 mg, heparin gtt,
atorvastatin 80 mg daily, metoprolol tartrate 25 mg [**Hospital1 **], and his
lisinopril was increased to 40 mg daily.  He underwent a cath
with placement of a bare metal stent to his left circumflex
artery.  After this, his plavix was changed to prasugrel 10 mg
daily because this does not interact with his fluoxetine or
omeprazole.  His transthoracic ECHO showed no wall motion
abnormalities, slight mitral regurgitation.  He was discharged
on: aspirin 81 mg, prasugrel 10 mg daily, atorvastatin 80 mg
daily, metoprolol succinate 50 mg [**Hospital1 **], and lisinopril 40 mg
daily.
.
# HTN:  His systolic pressure on admisson was 169 and so his
lisinopril was increased to 40 mg daily in light of NSTEMI as
would prefer to reduce afterload to reduce myocardial oxygen
demand.
.
# Gastroesophageal reflux disease (GERD):  This is chronic and
poorly controlled despite past [**Last Name (un) 1358**]. Has been on 40mg
omeprazole [**Hospital1 **] for some time.  Because PPI interacts with
clopidogrel, placed BMS so that anticoagulation time is
minimized.  Also, discharged him on prasugrel as 2nd
antiplatelet [**Doctor Last Name 360**] so that omeprazole can be continued.
.
# Depression:  Symptoms stable. Has been on high dose
fluoxetine. Fluoxetine also interacts with plavix so again
favored prasugrel in [**Hospital 4820**] medical management of NSTEMI.
.
# Siatica: Again long-standing and difficult to control.  His
PCP has reported that he trusts him to have narcotics on a
short-term basis if needed for pain while in house.  He is
getting set-up with the spine center for possible surgical
intervention.  Was given oxycodone for pain control but this
caused nightmares so he asked to not have this continued.
Avoided NSAIDS because don't want to irritate known gastritis in
the setting of new antiplatelet agents as above.
.
# CONTACT: [**Name (NI) 8214**] [**Name (NI) 83084**] (friend-[**Telephone/Fax (1) 83085**](h) /
[**Telephone/Fax (1) 83086**](w)
.
TRANSITIONAL ISSUES:
- Please discontinue prasugrel after a month if concerns for GI
bleeding
- His AST and ALT were slightly elevated and he was started on a
statin.  These should be rechecked

Medications on Admission:
Lisinopril 20mg PO daily
Omeprazole 40mg PO BID
Fluoxetine 40mg PO daily
ASA 81mg PO daily

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY DIAGNOSIS
non-ST elevation myocardial infarction (NSTEMI)
.
SECONDARY DIAGNOSIS
hypertension
gastroesophageal reflux disease (GERD)


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


Discharge Instructions:
Dear Mr. [**Known lastname 73466**],
.
You were admitted to the hospital because you had chest pain
which was concerning for a heart attack.  Your blood work showed
that you had a small heart attack and you underwent a procedure
(called cardiac catheterization) where they placed a stent in
one of your blood vessels to open it up again.  We also started
some new medications to control your blood pressure and
cholesterol.  Finally, there are some new medications to thin
your blood so that new blood clots are less likely to form in
your heart.  However, these medications do increase your risk of
bleeding in your stomach slightly so you should monitor yourself
for symptoms such as black stools.
.
The following changes were made to your medications:
- START taking prasugrel 10 mg daily
- START taking metoprolol succinate 50 mg a day
- START atorvastatin 80 mg daily
- INCREASE lisinopril to 40 mg daily
.
You should keep all of the follow-up appointments listed below.
.
It was a pleasure taking care of you in the hospital!

Followup Instructions:
Department: [**Location (un) **] PRIMARY CARE
When: TUESDAY [**2108-2-28**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 79306**], MD [**Telephone/Fax (1) 3736**]
Building: [**Street Address(2) 82764**] ([**Location 15289**], MA) [**Location (un) 859**]
Campus: OFF CAMPUS     Best Parking: Parking on Site

Department: [**Hospital3 249**]
When: MONDAY [**2108-2-27**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider.  [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.

Department: CARDIAC SERVICES
When: WEDNESDAY [**2108-3-21**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 18267**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Sciatica,Depressive disorder, not elsewhere classified'}


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: 65 year old male w/ PmHx of HTN and longstanding GERD (s/p
Nissen procedure) who presented to OSH with chest pain and found
to have elevated troponin without EKG changes, diagnosed with
NSTEMI and transfered to [**Hospital1 18**] for further evaluation.
Mr. [**Known lastname 73466**] reports that around 10am in the morning he developed
a pressure-like sensation around his sternum. He has prominent
GERD symptoms chronically and takes [**Hospital1 **] omeprazole, but this
felt different than his GERD symptoms and didn't feel like
anything he's ever had before. He devleoped diaphoresis, SOB,
and nausea with dry heaving shortly after the chest discomfort
started. He went to [**Hospital3 **] around 2pm. Initial EKG
showed no ischemic changes but troponin I there was elevated at
3.54. He was given 325mg ASA, 75mg clopidogrel, 2SL nitro, nitro
past, 4mg IV morphine, and 40mg simvastatin. Cardiology at
[**Hospital1 2436**] recommended transfer to [**Hospital1 18**].
On arrival to the [**Hospital1 18**] ED, inital VS: 97.4 67 147/107 18 100%
2L. EKG showed no ischemic changes. Guiac negative and started
on heparin gtt for troponin of 0.47 with CK 144 and CKMB 16.
Since chest pain was still present, was given 5mg IV morphine.
He was chest pain free at transfer to [**Hospital Ward Name 121**] 2 with Vs at transfer
97.8, 71, 162/90, 16, 99%RA.

MEDICAL HISTORY: Hiatal hernia, Nissen fundoplication [**2105-7-16**]
GERD
s/p ACL repair in [**2099**]
HTN
Depression
Peroneal nerve entrapemnt s/p surgical decompression in [**2102**]
B/l inguinal hernia repair in [**2102**]
Anemia
R should rotator cuff tear and biceps tendon tear in [**1-28**]

MEDICATION ON ADMISSION: Lisinopril 20mg PO daily
Omeprazole 40mg PO BID
Fluoxetine 40mg PO daily
ASA 81mg PO daily

ALLERGIES: Codeine / Amoxicillin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - Temp 98.0F, BP 166/99, HR 77, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, no focal deficits, intact sensation in
both LE without areas of numbness or paresthesias
BACK: mild pain to palpation over lower back and left SI joint
.
DISCHARGE PHYSICAL EXAM
VS Tmax 99.5, BP 110-140s/68-96, HR 60s, RR18, sats 100% RA
unchanged

FAMILY HISTORY: Father died of MI at age 70, mother and siblings are healthy

SOCIAL HISTORY: Wroked as a painter, physically active. Divorced, in a
monogamous relationship with girlfriend. [**Name (NI) 1139**] - greater than
30 pack years, quit in [**2088**], began smoking at age 12. Alcohol -
1-2 drinks beer daily, almost never binge drinks. No illicit/IV
drug use. 

### Response:
{'Subendocardial infarction, initial episode of care,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Esophageal reflux,Sciatica,Depressive disorder, not elsewhere classified'}
