CHIEF COMPLAINT: Chest pain, vaso-vagal response (bradycardic episodes X2)

PRESENT ILLNESS: Pt is a 31-yo man w/ no past medical history who presents with
chest pain. The pt's pain started at 4am yesterday morning,
awaking him from sleep. The pain is sharp ("like a vice around
the chest" and "like sticking a knife in and twisting it") with
some associated SOB. His pain progressively worsened over the
course of the day, and acutely worsened at about 10pm with sharp
pains, so he went to [**Hospital3 **]. There, while his blood was
being drawn, he became bradycardic and asystolic for [**6-28**]
seconds, with loss of pulses and consciousness, so CPR was
initiated. He received chest compressions but no ACLS
medications, with return of pulses and consciousness. He notes
that he always passes out when he sees needles, and he was not
feeling well afterwards, so he was transferred to the [**Hospital1 18**] ED
for further evaluation. Troponin and BNP negative prior to
transfer.
.
In the ED here, initial VS - Temp 99.6F, BP 136/79, HR 100, R
18, SaO2 98% 3L NC. He was noted to be pale and in continued
pain. His ECG showed S1Q3T3, and his labs were remarkable only
for WBC 14.6 (10 at OSH) and K 6.1 (moderately hemolyzed). Tox
screen was negative. He had another episode of bradycardia /
asystole here, while talking, with a drop in his blood pressure
to the 60s transiently, for which he received Atropine. He
underwent CTA Torso that was unrevealing except for aspiration
and ruled-out PE. While on the table for the CT-scan, after dye
injection, he became tachycardic to the 140s, which has since
been decreasing. He has also been noted to have occasional
desaturations. Given the thought that this might be a vagal
response, he underwent vigorous rectal stimulation, without
triggering similar changes. Cardiology was consulted in the ED,
and bedside TTE was planned. He was admitted to the CCU for
close monitoring.
.
On admission to the CCU, the pt noted continued left chest pain,
although improved from admission. He noted feeling feverish the
night before admission while out for dinner, but did not check
his temperature. He denies any palpitations, cough, or
hemoptysis. He notes baseline constipation, which is currently
no different from his usual state, but he does acknowledge LLQ
tenderness and right peri-umbilical pain today. No nausea/
vomiting or change in bowel habits. He recently returned from a
prolonged business trip to [**Country 651**](two weeks). He admits to
partaking local foods while visiting, and when he returned from
[**Country 651**] on [**2161-7-1**], he had a week of diarrhea his bowel
habits have since returned to his baseline. He does also admit
to uncomfortable mid-back/flank pain for several months.
.
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 exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, or
presyncope.
.
.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None, NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
VS: T= 100.4F, BP= 108/68, HR= 108, RR= 26, O2 sat= 91% 50%
Hi-[**Last Name (un) **].
GENERAL: WD/WN young man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. PERRL/EOMI. Sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Dry mucous membranes.
NECK: Supple without JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, 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. +TTP along left anterior and lateral chest
wall.
ABDOMEN: NABS, soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. +Mild TTP of LLQ.
EXTREMITIES: WWP, no c/c/e. No calf pain or tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
.
On disharge: AVSS. Same as on admission

FAMILY HISTORY: None
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

SOCIAL HISTORY: Single, lives with girlfriend. [**Name (NI) 1403**] as sales rep for
construction company. Also getting MBA, for which he had a
recent trip to [**Country 651**] and returned on [**2161-7-1**]. Had one week
diarrhea upon return from trip which has since resolved
-Tobacco history: none.
-ETOH: 6 drinks (beer + whiskey) / day x 3 days / week
-Illicit drugs: none.
.
Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Other chest pain
Food/vomit pneumonitis,Cardiac arrest,Chest pain NEC
Admission Date:  [**2161-7-17**]              Discharge Date:   [**2161-7-18**]

Date of Birth:  [**2130-2-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Chest pain, vaso-vagal response (bradycardic episodes X2)

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Pt is a 31-yo man w/ no past medical history who presents with
chest pain. The pt's pain started at 4am yesterday morning,
awaking him from sleep. The pain is sharp ("like a vice around
the chest" and "like sticking a knife in and twisting it") with
some associated SOB. His pain progressively worsened over the
course of the day, and acutely worsened at about 10pm with sharp
pains, so he went to [**Hospital3 **]. There, while his blood was
being drawn, he became bradycardic and asystolic for [**6-28**]
seconds, with loss of pulses and consciousness, so CPR was
initiated. He received chest compressions but no ACLS
medications, with return of pulses and consciousness. He notes
that he always passes out when he sees needles, and he was not
feeling well afterwards, so he was transferred to the [**Hospital1 18**] ED
for further evaluation. Troponin and BNP negative prior to
transfer.
.
In the ED here, initial VS - Temp 99.6F, BP 136/79, HR 100, R
18, SaO2 98% 3L NC. He was noted to be pale and in continued
pain. His ECG showed S1Q3T3, and his labs were remarkable only
for WBC 14.6 (10 at OSH) and K 6.1 (moderately hemolyzed). Tox
screen was negative. He had another episode of bradycardia /
asystole here, while talking, with a drop in his blood pressure
to the 60s transiently, for which he received Atropine. He
underwent CTA Torso that was unrevealing except for aspiration
and ruled-out PE. While on the table for the CT-scan, after dye
injection, he became tachycardic to the 140s, which has since
been decreasing. He has also been noted to have occasional
desaturations. Given the thought that this might be a vagal
response, he underwent vigorous rectal stimulation, without
triggering similar changes. Cardiology was consulted in the ED,
and bedside TTE was planned. He was admitted to the CCU for
close monitoring.
.
On admission to the CCU, the pt noted continued left chest pain,
although improved from admission. He noted feeling feverish the
night before admission while out for dinner, but did not check
his temperature. He denies any palpitations, cough, or
hemoptysis. He notes baseline constipation, which is currently
no different from his usual state, but he does acknowledge LLQ
tenderness and right peri-umbilical pain today. No nausea/
vomiting or change in bowel habits. He recently returned from a
prolonged business trip to [**Country 651**](two weeks). He admits to
partaking local foods while visiting, and when he returned from
[**Country 651**] on [**2161-7-1**], he had a week of diarrhea his bowel
habits have since returned to his baseline. He does also admit
to uncomfortable mid-back/flank pain for several months.
.
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 exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, or
presyncope.
.
.

Past Medical History:
None

1. CARDIAC RISK FACTORS: (-)Diabetes, (-)Dyslipidemia,
(-)Hypertension
2. CARDIAC HISTORY:
-CABG: none.
-PERCUTANEOUS CORONARY INTERVENTIONS: none.
-PACING/ICD: none.
3. OTHER PAST MEDICAL HISTORY: none.


Social History:
Single, lives with girlfriend. [**Name (NI) 1403**] as sales rep for
construction company. Also getting MBA, for which he had a
recent trip to [**Country 651**] and returned on [**2161-7-1**]. Had one week
diarrhea upon return from trip which has since resolved
-Tobacco history: none.
-ETOH: 6 drinks (beer + whiskey) / day x 3 days / week
-Illicit drugs: none.
.


Family History:
None
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

Physical Exam:
On admission:
VS: T= 100.4F, BP= 108/68, HR= 108, RR= 26, O2 sat= 91% 50%
Hi-[**Last Name (un) **].
GENERAL: WD/WN young man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. PERRL/EOMI. Sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Dry mucous membranes.
NECK: Supple without JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, 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. +TTP along left anterior and lateral chest
wall.
ABDOMEN: NABS, soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. +Mild TTP of LLQ.
EXTREMITIES: WWP, no c/c/e. No calf pain or tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
.
On disharge: AVSS. Same as on admission

Pertinent Results:
LABS/STUDIES

EKG: NSR @ 80bpm, NA/NI, +S1Q3T3, no acute ST-Twave changes
.
CXR: IMPRESSION: Mild aspiration pneumonia on atelectasis. Mild
cardiomegaly. Prominence of the mediastinum and interstitium may
be related to positioning and low lung volumes.
.
CTA CHEST/ABDOMEN/PELVIS ([**2161-7-17**]): Anomalous pulmonary vein
drainage into subclavian vein on the left side
CT Chest: Lungs with bibasilar atelectasis versus consolidation
and small bilateral pleural effusions; mild cardiomegaly with
LVH; pulmonary arteries and airways patent to segmental level;
no pericardial effusion.
CT Abdomen: Liver, spleen, adrenals, kidneys, gallbladder, and
pancreas unremarkable; abdominal loops of small bowel
unremarkable; no LAD.
CT Pelvis: Appendix, rectum, prostate, bladder, and ureters
unremarkable; sigmoid diverticulosis without diverticulitis; no
LAD.
Bone Windows: No lesion concerning for metastasis.
.
BEDSIDE TTE ([**2161-7-17**]) - focused windows: Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The number of aortic valve
leaflets cannot be determined. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
Second TTE ([**2161-7-17**]):
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. There is abnormal septal motion/position.

IMPRESSION: Mildly dilated right ventricle with mild systolic
dysfunction. Mild symmetric left ventricular hypertrophy with
preserved global and regional systolic function. No significant
valvular disease seen.
Compared with the prior study (images reviewed) of [**2161-7-17**],
right ventricular cavity is slightly smaller, and systolic
function has improved.

[**2161-7-17**] 01:40AM   GLUCOSE-119* UREA N-11 CREAT-1.0 SODIUM-140
POTASSIUM-6.1* CHLORIDE-107 TOTAL CO2-25 ANION GAP-14; REPEAT
POTASSIUM-4.3
[**2161-7-17**] 01:40AM   WBC-14.6* RBC-4.02* HGB-13.0* HCT-37.2*
MCV-93 MCH-32.4* MCHC-34.9 RDW-12.8;  NEUTS-80.6* LYMPHS-14.4*
MONOS-3.8 EOS-0.8 BASOS-0.4
[**2161-7-17**] 01:40AM   CK(CPK)-116, cTropnT-<0.01, CK-MB-2
[**2161-7-17**] 02:11PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-7-17**] 01:40AM   ALT(SGPT)-33 AST(SGOT)-48* LD(LDH)-500*
CK(CPK)-116 ALK PHOS-66 AMYLASE-22 TOT BILI-0.3, LIPASE 24


Brief Hospital Course:
31-M w/ no PMHx p/w chest pain and asystolic pause. Brief
hospital course by problem is as follows:
.
#. RHYTHM: Pt w/ bradycardia and asystolic pauses on telemetry,
unclear etiology. First episode seemed like vagal response to
appropriate stimulus, while second episode likely not
stimulated. Received CPR compressions after first episode,
atropine after second. During CCU stay, pads were kept on with
atropine at the bedside and close tele monitoring
.
#. Chest pain: Pt w/ unclear etiology for chest pain. Ruled-out
for MI. ECG and TTE findings concerning for PE but this
ruled-out by CTA. Pain was controlled with IV morphine and PO
Tylenol
.
#. Fever - With elevated WBC and recent low-grade temps, was
worked up for infectious processes. UA not suggestive of UTI.
CXR suggestive of aspiration pneumonia and pt started on
ceftriaxone and levofloxacin. Blood cx were still pending upon
discharge. Patient was discharged on levofloxacin alone for a
full 1 week course.
.
#. CORONARIES: Pt w/o known CAD, ECG was without evidence of
ischemia.
.
#. PUMP: Pt w/ bedside TTE done in ED to eval given chest pain
and negative CTA. Second TTE reiterated dilated right ventricle
and mild systolic dysfunction (improved). It was recommended
that pt get follow up cardiac MRI as outpatient to rule out
underlying structural abnormalities. Tox screen was also
negative. Lab draws were minimized and SQ heparin discontinued
secondary to pt's known vasovagal response to needles.
.


Medications on Admission:
None, NKDA

Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Vasovagal episodes, aspiration pneumonia


Discharge Condition:
Improved.
Vital signs stable, patient is ambulatory.


Discharge Instructions:
Please return to the ED if you experience any CP, SOB,
dizziness, nausea/vomiting. Please seek medical attention if you
have recurrent episodes of blacking out -- or if you have any
questions or concerns

Followup Instructions:
Follow up in Cardiology Clinic here at [**Hospital1 18**]. They will contact
you to arrange the appointment. If they do not call you in a few
days, call the Cardiology Clinic at ph: [**Telephone/Fax (1) 62**]

Follow up MRI of the heart. [**Hospital1 18**] will call you to arrange
appointment time. If they do not contact you within a few days,
call Radiology at ph: [**Telephone/Fax (1) 327**]
{'Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Other chest pain'}


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, vaso-vagal response (bradycardic episodes X2)

PRESENT ILLNESS: Pt is a 31-yo man w/ no past medical history who presents with
chest pain. The pt's pain started at 4am yesterday morning,
awaking him from sleep. The pain is sharp ("like a vice around
the chest" and "like sticking a knife in and twisting it") with
some associated SOB. His pain progressively worsened over the
course of the day, and acutely worsened at about 10pm with sharp
pains, so he went to [**Hospital3 **]. There, while his blood was
being drawn, he became bradycardic and asystolic for [**6-28**]
seconds, with loss of pulses and consciousness, so CPR was
initiated. He received chest compressions but no ACLS
medications, with return of pulses and consciousness. He notes
that he always passes out when he sees needles, and he was not
feeling well afterwards, so he was transferred to the [**Hospital1 18**] ED
for further evaluation. Troponin and BNP negative prior to
transfer.
.
In the ED here, initial VS - Temp 99.6F, BP 136/79, HR 100, R
18, SaO2 98% 3L NC. He was noted to be pale and in continued
pain. His ECG showed S1Q3T3, and his labs were remarkable only
for WBC 14.6 (10 at OSH) and K 6.1 (moderately hemolyzed). Tox
screen was negative. He had another episode of bradycardia /
asystole here, while talking, with a drop in his blood pressure
to the 60s transiently, for which he received Atropine. He
underwent CTA Torso that was unrevealing except for aspiration
and ruled-out PE. While on the table for the CT-scan, after dye
injection, he became tachycardic to the 140s, which has since
been decreasing. He has also been noted to have occasional
desaturations. Given the thought that this might be a vagal
response, he underwent vigorous rectal stimulation, without
triggering similar changes. Cardiology was consulted in the ED,
and bedside TTE was planned. He was admitted to the CCU for
close monitoring.
.
On admission to the CCU, the pt noted continued left chest pain,
although improved from admission. He noted feeling feverish the
night before admission while out for dinner, but did not check
his temperature. He denies any palpitations, cough, or
hemoptysis. He notes baseline constipation, which is currently
no different from his usual state, but he does acknowledge LLQ
tenderness and right peri-umbilical pain today. No nausea/
vomiting or change in bowel habits. He recently returned from a
prolonged business trip to [**Country 651**](two weeks). He admits to
partaking local foods while visiting, and when he returned from
[**Country 651**] on [**2161-7-1**], he had a week of diarrhea his bowel
habits have since returned to his baseline. He does also admit
to uncomfortable mid-back/flank pain for several months.
.
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 exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, or
presyncope.
.
.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None, NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
VS: T= 100.4F, BP= 108/68, HR= 108, RR= 26, O2 sat= 91% 50%
Hi-[**Last Name (un) **].
GENERAL: WD/WN young man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NC/AT. PERRL/EOMI. Sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Dry mucous membranes.
NECK: Supple without JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, 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. +TTP along left anterior and lateral chest
wall.
ABDOMEN: NABS, soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. +Mild TTP of LLQ.
EXTREMITIES: WWP, no c/c/e. No calf pain or tenderness.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP 2+ PT 2+
Left: Radial 2+ DP 2+ PT 2+
.
On disharge: AVSS. Same as on admission

FAMILY HISTORY: None
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory

SOCIAL HISTORY: Single, lives with girlfriend. [**Name (NI) 1403**] as sales rep for
construction company. Also getting MBA, for which he had a
recent trip to [**Country 651**] and returned on [**2161-7-1**]. Had one week
diarrhea upon return from trip which has since resolved
-Tobacco history: none.
-ETOH: 6 drinks (beer + whiskey) / day x 3 days / week
-Illicit drugs: none.
. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Other chest pain'}
