CHIEF COMPLAINT: Progressive pain and shortness of breath

PRESENT ILLNESS: 80 year old female with history of coronary artery disease
status post stents to the LAD and RCA, who presented for cath
today secondary to recently progressive anginal symptoms.  She
is the primary caregiver for her husband whom she transfers in
and out of a wheelchair; lately she has noted progressive,
intermittent discomfort of her left arm, associated with
dizziness and shortness of breath that are brought on by
exertion and are relieved with rest.  She has been using a
topical nitroglycerin patch more frequently, which has helped
somewhat.

MEDICAL HISTORY: 1) CAD:  Found to have multi-vessel disease at [**Hospital3 **] in
[**2156**] at which time her physicians recommended CABG, however the
patient preferred a more conservative approach, and proceeded
with 3 stents to the RCA and 2 stents to the LAD.  Had left
heart catheterization 2 years ago with clean coronaries.
2) Hyperlipidemia
3) Left breast cancer, status post XRT and lumpectomy
approximately 7 years ago
4) Cholecystectomy
5) Right hip fracture status post repair
6) Melanoma of the right arm, status post resection
7) Short term memory deficits (per daughter)

MEDICATION ON ADMISSION: Nitroglycerin patch 0.4mg QAM, OFF QPM
Toprol XL 25mg QAM
Lipitor 40mg QAM
Triamterene/HCTZ 37.5-25mg QAM
Tricor 145mg QAM
KCL 20meq QAM
Aspirin 81mg QAM
MVI QAM

ALLERGIES: Irbesartan

PHYSICAL EXAM: ON ARRIVAL TO CCU AFTER CATH:
97.1, 125/72, 121, 19, 98% on 2L NC.
GENERAL:  Obese caucasian female appearing slightly
uncomfortable.
MS:  Responds to questions appropriately.
HEENT:  Dry mucous membranes.  Anicteric sclerae.
COR:  RR, tachycardic, no murmurs/rubs/gallops.
LUNGS:  Clear to auscultation bilaterally.
ABD:  Normoactive bowel sounds.  Large mass palpated
subcutaneously in R abdomen extending to midline medially and
towards flank laterally, tender.
EXTR:  DP/PT palpable bilaterally, feet cool.

FAMILY HISTORY: Father and brother with CAD.

SOCIAL HISTORY: Married, husband is wheelchair bound.  She has been his primary
caretaker, however he is currently in a nursing home.
Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia
Crnry athrscl natve vssl,Intermed coronary synd,Hematoma complic proc,Ac posthemorrhag anemia,Abn react-cardiac cath,Hypertension NOS,Hx-skin malignancy NEC,Hx of breast malignancy,Hyperlipidemia NEC/NOS
Admission Date:  [**2167-6-30**]              Discharge Date:   [**2167-7-5**]

Date of Birth:  [**2086-10-27**]             Sex:   F

Service: MEDICINE

Allergies:
Irbesartan

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Progressive pain and shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization [**6-30**] with drug eluting stent to the left
circumflex artery.

History of Present Illness:
80 year old female with history of coronary artery disease
status post stents to the LAD and RCA, who presented for cath
today secondary to recently progressive anginal symptoms.  She
is the primary caregiver for her husband whom she transfers in
and out of a wheelchair; lately she has noted progressive,
intermittent discomfort of her left arm, associated with
dizziness and shortness of breath that are brought on by
exertion and are relieved with rest.  She has been using a
topical nitroglycerin patch more frequently, which has helped
somewhat.

Of note, she had a nuclear stress in [**8-11**] during which she
exercised 4 minutes (6 mets) to 78% predicted heart rate, with
possibly mild posterolateral and apical ischemia.  Her EF was
71%.  She declined a catheterization, but agreen to CT
angiography on [**2167-5-26**] which revealed significant in-stent
restenosis within the proximal LAD and proximal RCA, as well as
moderate to severe plaque in the proximal LCx, prompting
referral to [**Hospital1 18**].

Past Medical History:
1) CAD:  Found to have multi-vessel disease at [**Hospital3 **] in
[**2156**] at which time her physicians recommended CABG, however the
patient preferred a more conservative approach, and proceeded
with 3 stents to the RCA and 2 stents to the LAD.  Had left
heart catheterization 2 years ago with clean coronaries.
2) Hyperlipidemia
3) Left breast cancer, status post XRT and lumpectomy
approximately 7 years ago
4) Cholecystectomy
5) Right hip fracture status post repair
6) Melanoma of the right arm, status post resection
7) Short term memory deficits (per daughter)

Social History:
Married, husband is wheelchair bound.  She has been his primary
caretaker, however he is currently in a nursing home.

Family History:
Father and brother with CAD.

Physical Exam:
ON ARRIVAL TO CCU AFTER CATH:
97.1, 125/72, 121, 19, 98% on 2L NC.
GENERAL:  Obese caucasian female appearing slightly
uncomfortable.
MS:  Responds to questions appropriately.
HEENT:  Dry mucous membranes.  Anicteric sclerae.
COR:  RR, tachycardic, no murmurs/rubs/gallops.
LUNGS:  Clear to auscultation bilaterally.
ABD:  Normoactive bowel sounds.  Large mass palpated
subcutaneously in R abdomen extending to midline medially and
towards flank laterally, tender.
EXTR:  DP/PT palpable bilaterally, feet cool.


Pertinent Results:
[**2167-6-30**] Hct-28.4*
[**2167-6-30**] Hct-26.6*
[**2167-6-30**] Hct-33.5*
[**2167-7-1**] Hct-31.4*
[**2167-7-1**] Hct-31.2*
[**2167-7-1**] Hct-25.5*
[**2167-7-2**] WBC-7.7 RBC-3.62* Hgb-10.8* Hct-29.3* MCV-81* MCH-29.7
MCHC-36.7* RDW-16.2* Plt Ct-115*
[**2167-7-2**] WBC-7.6 RBC-4.16* Hgb-12.3 Hct-33.8* MCV-81* MCH-29.5
MCHC-36.3* RDW-16.3* Plt Ct-109*
[**2167-7-2**] Hct-30.9*
[**2167-7-3**] WBC-6.7 RBC-3.59* Hgb-10.7* Hct-28.7* MCV-80* MCH-29.8
MCHC-37.2* RDW-16.2* Plt Ct-103*
[**2167-7-3**] Hct-35.1*
[**2167-7-4**] WBC-6.9 RBC-3.94* Hgb-11.4* Hct-32.6* MCV-83 MCH-29.0
MCHC-35.0 RDW-15.9* Plt Ct-135*

[**2167-6-30**] PT-14.2* PTT-26.1 INR(PT)-1.3*

[**2167-6-30**] Glucose-166* UreaN-18 Creat-0.8 Na-143 K-3.9 Cl-112*
HCO3-22

[**2167-6-30**] Calcium-7.8* Phos-3.1 Mg-1.5*

EKG [**2167-6-30**]:  Sinus bradycardia
Right bundle branch block
Probable left anterior fascicular block

CATH [**2167-6-30**]:  COMMENTS:
1)  Selective coronary angiography in this right dominant system

revealed two vessel coronary artery disease.  The LMCA was
normal.  The
LAD was diffusely diseased with up to 30% stenoses.  The LAD
stent was
widely patent.  The LCx had diffuse disease with a 70% proximal
and a
50% mid segment stenosis.  The RCA had diffuse disease with a
40%
stenosis in the mid segement. The RCA stents were patent.
2)  Left ventriculography was deferred because the ejection
fraction
was assessed non-invasively.
3)  Central aortic pressure was elevated at 174/72 mmHg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.

FEMORAL VASCULAR ULTRASOUND RIGHT [**2167-7-1**]:
FINDINGS: Duplex color Doppler of the right femoral area was
performed. No pseudoaneurysm or AV fistula was identified. A
small hematoma was seen.

CT ABDOMEN AND PELVIS [**2167-7-2**]:  IMPRESSION:
1. Large retroperitoneal hematoma measuring 25 x 10 x 6 cm.
2. Small/moderate right pleural effusion with associated
atelectasis. These findings were discussed with Dr. [**Last Name (STitle) **] at
2:30 p.m. on [**2167-7-2**].

Brief Hospital Course:
In brief, 80 year old female with CAD status post multiple prior
LAD and RCA stents, who presented for cath in evaluation of
progressive angina, found to have 70% LCx lesion that was
stented, with post-cath hypotension and hematocrit drop
secondary to large retroperitoneal hematoma, supported with
blood products with return of hemodynamic stability, and no
further anginal symptoms while in house.

Hospital course summarized in more detail as follows:

1) Coronary artery disease:  The patient underwent cath, which
demonstrated patent LAD and RCA stents, with 70% proximal and
50% mid LCx stenoses, the proximal of which was stented with a
3.0 cypher stent.  The access site was quite high (above the
inguinal ligament), so angioseal was used.  She was transfered
to the floor hemodynamically stable, however shortly thereafter
her blood pressure was noted to decline to 80s-90s systolic,
along with a hematocrit drop from 35.1 to 28.4.  Dopamine was
started peripherally on the floor, with aggressive PRBC
resuscitation, however the blood pressure remained low and the
patient was taken back to the cath lab.

In the cath lab there was suggestion of a slow ooze from near
the access site, however it was difficult to conclusively
identify the a source.  Nevertheless, the hematoma along the
right inguinal area had rapidly expanded in size, and was felt
likely to be a large pseudoaneurysm, possibly with
retroperitoneal bleed.  Left and right sided pressures were both
low, with a wedge of 4.  She was transferred to the CCU where,
over the course of the subsequent 3-4 days she received
aggressive volume resuscitation with 10 units of PRBCs and many
liters of fluid.  Her hematocrit eventually stabilized, and her
hemodynamics were stable enough to allow a CT of the abdomen,
which did confirm a large retroperitoneal hematoma.  She
remained hemodynamically stable, without transfusion requirement
for the remainder of the hospitalization.

In terms of ongoing medical management of her CAD, she was
continued on ASA and plavix throughout, and will remain on these
until further notice.  Her beta blocker was held in the setting
of her bleed, however restarted and titrated up without
difficulty subsequently.  Her Toprol XL was increased from 25 on
admission to 50 mg daily.  Her atorvastatin was increased from
40 to 80 mg daily.  She was continued on Tricor for
hypertriglyceridemia.

3) Rash: Patient developed a rash just after a dose of morphine.
 Likely, due to mast cell reaction triggered by morphine.
Dissipated rapidly with IV benadryl.  This should not preclude
further doses of morphine should they be necessary, as this is
not an allergy.

4) FEN:  She ate a cardiac/heart healthy diet.

5) Prophylaxis:  She was given pneumoboots.

6) Code:  Full.

7) Physical therapy saw the patient prior to discharge and they
recommended one more session of PT. They then cleared her to go
home.

Medications on Admission:
Nitroglycerin patch 0.4mg QAM, OFF QPM
Toprol XL 25mg QAM
Lipitor 40mg QAM
Triamterene/HCTZ 37.5-25mg QAM
Tricor 145mg QAM
KCL 20meq QAM
Aspirin 81mg QAM
MVI QAM


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*20 Tablet Sustained Release 24HR(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Coronary artery disease
Unstable angina
Retroperitoneal hematoma
Blood loss anemia

Secondary:
Hyperlipidemia
Hypertension


Discharge Condition:
Improved, stable hematocrit, ambulating independently.


Discharge Instructions:
Please take all of your medications as directed.

We have started you on one new medication called Plavix
(clopidogrel) that you MUST make sure to take EVERY DAY without
fail.  This medication keeps the stents in the vessels of your
heart open, and missing even one day can lead to recurrent
blockage of your arteries.

We have increased you daily aspirin to 325 mg (this is a higher
dose than the 81 mg you were previously taking).  You can buy
this over the counter if it is less expensive for you.

We have DISCONTINUED your triamterene/hydrochlorothiazide tablet
since your blood pressure was well controlled without it while
you were here.  You should NOT take this medication anymore.

We have increased your atorvastatin to 80 mg daily (this is
double your old dose, so you may take 2 of your old pills at a
time until you run and and fill your new prescription).

We have also increased your dose of Toprol XL from 25 mg daily
to 50 mg daily for better blood pressure control.

Please seek medical help if you experience any further chest
pain, shortness of breath, lightheadedness, or just have
concerns.


Followup Instructions:
Please call to make an appointment with Dr. [**Last Name (STitle) 11250**] within
the next 1-2 weeks ([**Telephone/Fax (1) 11254**]).

You should also see your primary care doctor, Dr. [**First Name (STitle) 5699**],
within the next month ([**Telephone/Fax (1) 26545**]).


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia'}


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: Progressive pain and shortness of breath

PRESENT ILLNESS: 80 year old female with history of coronary artery disease
status post stents to the LAD and RCA, who presented for cath
today secondary to recently progressive anginal symptoms.  She
is the primary caregiver for her husband whom she transfers in
and out of a wheelchair; lately she has noted progressive,
intermittent discomfort of her left arm, associated with
dizziness and shortness of breath that are brought on by
exertion and are relieved with rest.  She has been using a
topical nitroglycerin patch more frequently, which has helped
somewhat.

MEDICAL HISTORY: 1) CAD:  Found to have multi-vessel disease at [**Hospital3 **] in
[**2156**] at which time her physicians recommended CABG, however the
patient preferred a more conservative approach, and proceeded
with 3 stents to the RCA and 2 stents to the LAD.  Had left
heart catheterization 2 years ago with clean coronaries.
2) Hyperlipidemia
3) Left breast cancer, status post XRT and lumpectomy
approximately 7 years ago
4) Cholecystectomy
5) Right hip fracture status post repair
6) Melanoma of the right arm, status post resection
7) Short term memory deficits (per daughter)

MEDICATION ON ADMISSION: Nitroglycerin patch 0.4mg QAM, OFF QPM
Toprol XL 25mg QAM
Lipitor 40mg QAM
Triamterene/HCTZ 37.5-25mg QAM
Tricor 145mg QAM
KCL 20meq QAM
Aspirin 81mg QAM
MVI QAM

ALLERGIES: Irbesartan

PHYSICAL EXAM: ON ARRIVAL TO CCU AFTER CATH:
97.1, 125/72, 121, 19, 98% on 2L NC.
GENERAL:  Obese caucasian female appearing slightly
uncomfortable.
MS:  Responds to questions appropriately.
HEENT:  Dry mucous membranes.  Anicteric sclerae.
COR:  RR, tachycardic, no murmurs/rubs/gallops.
LUNGS:  Clear to auscultation bilaterally.
ABD:  Normoactive bowel sounds.  Large mass palpated
subcutaneously in R abdomen extending to midline medially and
towards flank laterally, tender.
EXTR:  DP/PT palpable bilaterally, feet cool.

FAMILY HISTORY: Father and brother with CAD.

SOCIAL HISTORY: Married, husband is wheelchair bound.  She has been his primary
caretaker, however he is currently in a nursing home. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Intermediate coronary syndrome,Hematoma complicating a procedure,Acute posthemorrhagic anemia,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified essential hypertension,Personal history of other malignant neoplasm of skin,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia'}
