CHIEF COMPLAINT: Substernal chest pressure, weakness

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was in her usual state
of health, living independently with a history of DM, HTN, CAD,
HL, and CRI who presented to [**Hospital1 18**] on [**2176-6-5**] after transfer
from [**Hospital3 628**] after experiencing susbternal chest pain,
shortness of breath, and weakness which caused her to collapse.
EMS found her to be at 55% O2 saturation which improved when
placed on a 100% non-rebreather mask and given sublingual
nitroglycerin and placed on a nitro drip. The patient was
reported to have elevated CKs and Troponins at the outside
hospital with an EKG showing an old LBBB at a rate of [**Street Address(2) 34511**] changes that did not ischemic criteria. She was
transferred to [**Hospital1 18**] for possible cardiac catheterization and
further evaluation. On the telemetry floor at [**Hospital1 18**], the patient
developed new onset shortness of breath and the suspicion
remained of an ischemic cause. Her troponin on [**2176-6-6**] was 0.41,
0.57, MB of 10, 24, and CPK of 156, 283. Her EKG showed no acute
changes.

MEDICAL HISTORY: DM
HL
HTN
Chronic renal insufficiency

MEDICATION ON ADMISSION: Atenolol 100 mg, Norvasc, Lasix, LesCol

ALLERGIES: Lopid

PHYSICAL EXAM: T = 97.7 BP 159/79  HR 82  RR 29  Wt. 49.6 kg 88% O2 on 100% NRB
and 1 L NC

FAMILY HISTORY: 

SOCIAL HISTORY: She is retired and widowed and lives alone. She denies any
smoking or alcohol use.
Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Mitral valve disorders,Diseases of tricuspid valve,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Other emphysema,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Subendo infarct, initial,CHF NOS,Mitral valve disorder,Tricuspid valve disease,Gastrointest hemorr NOS,Pneumonia, organism NOS,Emphysema NEC,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2176-6-6**]              Discharge Date:   [**2176-6-14**]


Service: [**Hospital Unit Name 196**]

Allergies:
Lopid

Attending:[**First Name3 (LF) 5295**]
Chief Complaint:
Substernal chest pressure, weakness

Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a [**Age over 90 **] year old female who was in her usual state
of health, living independently with a history of DM, HTN, CAD,
HL, and CRI who presented to [**Hospital1 18**] on [**2176-6-5**] after transfer
from [**Hospital3 628**] after experiencing susbternal chest pain,
shortness of breath, and weakness which caused her to collapse.
EMS found her to be at 55% O2 saturation which improved when
placed on a 100% non-rebreather mask and given sublingual
nitroglycerin and placed on a nitro drip. The patient was
reported to have elevated CKs and Troponins at the outside
hospital with an EKG showing an old LBBB at a rate of [**Street Address(2) 34511**] changes that did not ischemic criteria. She was
transferred to [**Hospital1 18**] for possible cardiac catheterization and
further evaluation. On the telemetry floor at [**Hospital1 18**], the patient
developed new onset shortness of breath and the suspicion
remained of an ischemic cause. Her troponin on [**2176-6-6**] was 0.41,
0.57, MB of 10, 24, and CPK of 156, 283. Her EKG showed no acute
changes.

Past Medical History:
DM
HL
HTN
Chronic renal insufficiency

Social History:
She is retired and widowed and lives alone. She denies any
smoking or alcohol use.

Physical Exam:
T = 97.7 BP 159/79  HR 82  RR 29  Wt. 49.6 kg 88% O2 on 100% NRB
and 1 L NC

General - confused, moderate respiratory distress, not oriented
to time or place
CV - + JVD to the angle of her jaw, holosystolic Grade II/VI
murmur radiating to axilla, with clear S1 and S2
Lungs - diffuse bilateral crackles and wheezes
Abdomen - soft, nontender, nondistended with active bowel sounds
Extremities - no cyanosis or clubbing, +1 dorsalis pedis
bilaterally, +2 pitting edema bilaterally in lower extremities
to mid-calf


Pertinent Results:
[**2176-6-6**] 08:20PM   GLUCOSE-198* UREA N-31* CREAT-1.8* SODIUM-144
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-22 ANION GAP-20
[**2176-6-6**] 08:20PM   CK(CPK)-325*
[**2176-6-6**] 08:20PM   CK-MB-22* MB INDX-6.8*
[**2176-6-6**] 08:20PM   CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9
[**2176-6-6**] 08:20PM   WBC-17.1* RBC-3.19* HGB-9.4* HCT-27.7* MCV-87
MCH-29.4 MCHC-33.8 RDW-14.0
[**2176-6-6**] 08:20PM   PLT COUNT-140*
[**2176-6-6**] 08:20PM   PT-14.7* PTT-58.8* INR(PT)-1.4
[**2176-6-6**] 11:40AM   TYPE-ART TEMP-36.1 O2-100 PO2-58* PCO2-47*
PH-7.30* TOTAL CO2-24 BASE XS--3 AADO2-625 REQ O2-99
INTUBATED-NOT INTUBA
[**2176-6-6**] 11:40AM   LACTATE-1.4 K+-3.9
[**2176-6-6**] 11:40AM   HGB-10.2* calcHCT-31
[**2176-6-6**] 11:40AM   freeCa-1.21
[**2176-6-6**] 11:37AM   CK(CPK)-283*
[**2176-6-6**] 11:37AM   CK-MB-24* MB INDX-8.5* cTropnT-0.57*
[**2176-6-6**] 05:40AM   CK(CPK)-156*
[**2176-6-6**] 05:40AM   cTropnT-0.41*
[**2176-6-6**] 05:40AM   CK-MB-10 MB INDX-6.4*
[**2176-6-6**] 05:40AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2176-6-6**] 05:40AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2176-6-6**] 05:40AM URINE  RBC-[**2-16**]* WBC-<1 BACTERIA-OCC YEAST-NONE
EPI-0-2

Brief Hospital Course:
1. Cardiac -
Rhythm: Pt. was transferred to CCU where she remained in sinus
rhythm with occasional premature atrial contractions.
Pump: An echocardiogram on [**2176-6-7**] showed her to have diastolic
dysfunction with an EF of 50% with mild global LV hypokinesis,
[**12-15**]+ moderate mitral regurgitation and tricuspid regurgitation,
and mild pulmonary hypertension. Her CHF was treated with
aggressive diuresis with Lasix with a goal of maintaing her net
negative by 1-1.5 L as her renal function tolerated. A nitro
drip was continued for symptomatic relief and decreased preload.
She was initially started on Captopril 6.25 mg TID which was
later D/C'd on [**2176-6-8**] secondary to renal dysfunction. She would
then occasionally desaturate to the high 80's, low 90s O2 sat
with improvement on lasix, aggressive pulmonary toilet, and
albuterol nebs. She was placed on Natrecor .01 on [**2176-6-8**] which
was quickly discontinued secondary to an episode of hypotension.
The nitro drip was converted to isosorbide dinitrate 20 mg TID
on [**2176-6-12**] which was later changed to Imdur 60 mg PO QD. Repeat
chest xrays showed significant improvement with her pulmonary
edema with the last on [**2176-6-13**] showed small residual pleural
effusion on the right. Hydralazine 10 mg QID was started briefly
and changed to Norvasc 5 mg PO QD for blood pressure control.
CAD: s/p NSTEMI. The plan for intervention vs. medical
management was discussed with the family as well as the
risk/benefits. They decided to pursue medical management. The
patient was continued on a heparin drip which was D/C'd on
[**2176-6-9**]. She was continued on Plavix, a statin, ASA, and a
beta-blocker. On [**2176-6-11**], sagging ST segments were noted on EKG
inferiorly and her peak CPK was 515, MBI 2, and Troponin 1.37.
The patient experienced mild chest pain on the morning of
[**2176-6-12**] which was relieved with morphine. Cardiac enzymes
continued to trend down and the patient remained asymptomatic.
2. Pulmonary - Presented with pulmonary edema which resolved
with aggressive diuresis. Question of residual pleural
infiltrate/effusion on right on chest xray and assymmetric lung
exam so was started on Levofloxacin 250 mg PO Q48 on [**2176-6-11**] for
a 7 day course to cover for possible pneumonia. The patient
developed a cough and had a Tmax of 100.6. Legionella antigen
proved negative. She was able to wean finally on [**2176-6-13**] off the
cool O2 nebulizer to 6L nasal cannula and then to 3 L NC without
difficulty.
3. DM - The patient was continued on a sliding scale insulin and
diabetic diet.
4. GI - The patient experienced a few episodes of black tarry
stool and was intermittently noted to have guaiac postive
stools. It was felt that once her acute cardiac issues were
resolved and her GI bleed continued, the plan would be discussed
with the family to ensure that the patient's wishes were
respected in terms of aggressive vs.
5. Heme - The patient's hematocrit dropped once to 26 for which
she received 1 unit of PRBC and has remained stable since.

The patient was discharged to [**Location (un) 1036**] on [**2176-6-14**] in good
condition with resolution of her pulmonary edema, decreased
cardiac enzymes, and increased mobility and po intake.


Medications on Admission:
Atenolol 100 mg, Norvasc, Lasix, LesCol

Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Pilocarpine HCl 0.5 % Drops Sig: One (1) Drop Ophthalmic  Q8H
(every 8 hours).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day): Continue for a total of 8 more months.
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 3 days: Continue for 3 more days.
8. Albuterol Sulfate 0.083 % Solution Sig: [**12-15**]  Inhalation Q6H
(every 6 hours) as needed.
9. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for COUGH.
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO QD (once a day).
11. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1 and a half Tablet Sustained Release 24HR PO QD (once a
day).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 1036**] - [**Location (un) 620**]

Discharge Diagnosis:
Non-ST elevation myocardial infarction with acute congestive
heart failure exacerbation
Probable Pneumonia

Discharge Condition:
Good.

Discharge Instructions:
For blood pressure control and renal protection in CHF and
diabetes, ACE-I may be restarted once creatinine returns to
baseline of 1.5-1.8 (would favor stopping Norvasc at that time).
Monitor fluid status, euvolemic on discharge, goal to remain I/O
even, responds to Lasix prn if needed
Monitor O2 sats, maintain on 3 L O2 nasal cannula as needed with
goal to wean off O2 as tolerated, not on O2 at home
Monitor daily weights, keep near 49.6 kg
Complete antibiotic course (total 7 days)
Fingersticks QID, h/o DM, SSI


Followup Instructions:
Provider: [**Name10 (NameIs) 6121**],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 8477**]  Call to schedule
appointment
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Mitral valve disorders,Diseases of tricuspid valve,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Other emphysema,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: Substernal chest pressure, weakness

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was in her usual state
of health, living independently with a history of DM, HTN, CAD,
HL, and CRI who presented to [**Hospital1 18**] on [**2176-6-5**] after transfer
from [**Hospital3 628**] after experiencing susbternal chest pain,
shortness of breath, and weakness which caused her to collapse.
EMS found her to be at 55% O2 saturation which improved when
placed on a 100% non-rebreather mask and given sublingual
nitroglycerin and placed on a nitro drip. The patient was
reported to have elevated CKs and Troponins at the outside
hospital with an EKG showing an old LBBB at a rate of [**Street Address(2) 34511**] changes that did not ischemic criteria. She was
transferred to [**Hospital1 18**] for possible cardiac catheterization and
further evaluation. On the telemetry floor at [**Hospital1 18**], the patient
developed new onset shortness of breath and the suspicion
remained of an ischemic cause. Her troponin on [**2176-6-6**] was 0.41,
0.57, MB of 10, 24, and CPK of 156, 283. Her EKG showed no acute
changes.

MEDICAL HISTORY: DM
HL
HTN
Chronic renal insufficiency

MEDICATION ON ADMISSION: Atenolol 100 mg, Norvasc, Lasix, LesCol

ALLERGIES: Lopid

PHYSICAL EXAM: T = 97.7 BP 159/79  HR 82  RR 29  Wt. 49.6 kg 88% O2 on 100% NRB
and 1 L NC

FAMILY HISTORY: 

SOCIAL HISTORY: She is retired and widowed and lives alone. She denies any
smoking or alcohol use. 

### Response:
{'Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Mitral valve disorders,Diseases of tricuspid valve,Hemorrhage of gastrointestinal tract, unspecified,Pneumonia, organism unspecified,Other emphysema,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
