CHIEF COMPLAINT: STEMI

PRESENT ILLNESS: 80-year-old male with history of hypertension, TIA, EtOH abuse
presents from orthopedics preop for hip surgery with EKG changes
concerning STEMI.
.
The patient was in his usual state of health until a couple
weeks prior to presentation. At that time he had intermittent
"fleeting" upper chest burning, which radiation to the jaw,
worse with exertion and quickly improved with rest. Over the
last 2 days the patient states the burning discofort has gotten
worse. He attributed the pain to "heartburn" although denies
prior symptoms of GERD and there was no relationship to eating.
He took prilosec without relief. He also notes fatigue and
insomnia. He denies nausea, vomiting, diaphoresis, or SOB. He
also notes some left scapular pain "twinges" associated with
movement during these episodes.
.
In the ED a code STEMI was called. The patient was given 600mg
PO plavix, heparin bolus and gtt, aspirin and atorvastatin. In
the cath lab they found a chronically occluded RCA, mid-LAD
lesion treated with BMS, LCx with moderate disease. The patient
was admitted to the CCU.
.
On review of systems: (-) chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, presyncope, stroke, DVT, PE, myalgias,
cough, hemoptysis, melena, hematochezia, fevers, chills.
(+) TIA, OA

MEDICAL HISTORY: 1. Hypertension
2. TIA - 22 years prior - slurred speech
3. Bladder CA - s/p TURP
4. Renal mass - stable cyst
5. Depression - 22 years, since wife died
6. Macular degeneration
7. EtOH abuse, distant past
8. Xanax abuse, distant past
9. Osteoarthritis - L hip pain, secondary to car accident 21
years ago
.

MEDICATION ON ADMISSION: 1. Aspirin 81 mg Tablet PO DAILY
2. Lasix 20 mg PO daily(no swollen legs, SOB, CHF, per patient
due to difficult to control blood pressure)
3. Lisinopril 10 mg PO BID
4. Amlodipine 2.5 mg daily
5. Oxycodone 10mg PO q6H PRN pain
6. Ibuprofen unknown dose PRN pain
7. Remeron 45 mg q hs
8. Flexaril 5mg 1-2 tabs at hs
9. Trazadone 50 mg 1-2 tabs at hs
10. Doxazosin 1mg at hs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= 98.3...BP=142/77...HR=100...RR=15-25...O2 sat=100%  on 3L
GENERAL: WDWN in NAD. Oriented x3. 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: deceased liver cancer
Father: deceased MI - age - 60-years-old
Brother: deceased renal cell carcinoma
Children: x3, healthy

SOCIAL HISTORY: Lives alone, oldest daughter lives downstairs. Formerly worked
as mechanic for [**Company 2318**].
-Tobacco history: 50 pack year history, quit 30 days ago
-ETOH: Denies, history of heavy drinking, last drink 10 years
ago
-Illicit drugs: Xanax abuse
Acute myocardial infarction of anterolateral wall, initial episode of care,Acute combined systolic and diastolic heart failure,Coronary atherosclerosis of native coronary artery,Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of bladder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension
AMI anterolateral, init,Ac syst/diastol hrt fail,Crnry athrscl natve vssl,Loc osteoarth NOS-pelvis,Chr pulmon heart dis NEC,Depressive disorder NEC,Hx of bladder malignancy,Hx TIA/stroke w/o resid,Hypertension NOS
Admission Date:  [**2143-2-4**]              Discharge Date:   [**2143-2-7**]

Date of Birth:  [**2062-8-29**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
STEMI

Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stent to left anterior
descending artery.


History of Present Illness:
80-year-old male with history of hypertension, TIA, EtOH abuse
presents from orthopedics preop for hip surgery with EKG changes
concerning STEMI.
.
The patient was in his usual state of health until a couple
weeks prior to presentation. At that time he had intermittent
"fleeting" upper chest burning, which radiation to the jaw,
worse with exertion and quickly improved with rest. Over the
last 2 days the patient states the burning discofort has gotten
worse. He attributed the pain to "heartburn" although denies
prior symptoms of GERD and there was no relationship to eating.
He took prilosec without relief. He also notes fatigue and
insomnia. He denies nausea, vomiting, diaphoresis, or SOB. He
also notes some left scapular pain "twinges" associated with
movement during these episodes.
.
In the ED a code STEMI was called. The patient was given 600mg
PO plavix, heparin bolus and gtt, aspirin and atorvastatin. In
the cath lab they found a chronically occluded RCA, mid-LAD
lesion treated with BMS, LCx with moderate disease. The patient
was admitted to the CCU.
.
On review of systems: (-) chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, presyncope, stroke, DVT, PE, myalgias,
cough, hemoptysis, melena, hematochezia, fevers, chills.
(+) TIA, OA

Past Medical History:
1. Hypertension
2. TIA - 22 years prior - slurred speech
3. Bladder CA - s/p TURP
4. Renal mass - stable cyst
5. Depression - 22 years, since wife died
6. Macular degeneration
7. EtOH abuse, distant past
8. Xanax abuse, distant past
9. Osteoarthritis - L hip pain, secondary to car accident 21
years ago
.

Social History:
Lives alone, oldest daughter lives downstairs. Formerly worked
as mechanic for [**Company 2318**].
-Tobacco history: 50 pack year history, quit 30 days ago
-ETOH: Denies, history of heavy drinking, last drink 10 years
ago
-Illicit drugs: Xanax abuse

Family History:
Mother: deceased liver cancer
Father: deceased MI - age - 60-years-old
Brother: deceased renal cell carcinoma
Children: x3, healthy

Physical Exam:
VS: T= 98.3...BP=142/77...HR=100...RR=15-25...O2 sat=100%  on 3L
GENERAL: WDWN in NAD. Oriented x3. 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 JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, soft 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. Anterior and axillary
lung fields were CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.  Nml BS.
EXTREMITIES: No c/c/e. R fem insertion site without hematoma,
minimal ecchymosis.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: 2+ Popliteal 2+ DP 2+ PT 2+
Left: Popliteal 2+ DP 2+ PT 2+
Neuro: CN II-XII intact, motor/sensation grossly intact.

Discharge exam unchanged.

Pertinent Results:
[**2143-2-4**] cardiac catherization:

1. Selective coronary angiography in this right dominant system
demonstrated three vessel coronary artery disease.  The LAD was
diffusely disease proximally wiht a 40% stenosis.  The mid LAD
was 100%
occluded just following a large first diagonal branch.  The LCx
had a
60% mid vessel and an 80% distal vessel stenosis.  The RCA had a
100%
proximal stenosis and filled distally via left to right
collaterals.
2. Limited resting hemodynamics revealed mildly elevated left
sided
filling pressure wiht PCWP 21 mmHg and mild pulmonary systolic
arterial
hypertension PASP 38 mmHg.  The cardiac index was mildly
depressed at
2.0 l/min/m2.
3.  Left ventriculography was deferred.
4.  Successful PCI of the mid-LAD with a 2.5x18mm Vision bare
metal
stent.
5.  Successful closure of the right femoral arteriotomy site
with a
Perclose device.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild pulmonary hypertension.
3. Successful PCI of the LAD with BMS.

[**2143-2-5**] Echo:

The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
focal hypokinesis to akinesis of the mid to distal septum,
anterior wall, apex, and distal inferior wall. The remaining
segments contract normally (LVEF = 35-40 %). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**12-22**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.

IMPRESSION: Regional left ventricular systolic dysfunction c/w
LAD myocardial infarction. Mild to moderate mitral
regurgitation.

Compared with the prior study (images reviewed) of [**2142-7-5**],
regional ventricular dysfunction is new. Estimated pulmonary
artery pressures are lower.


Brief Hospital Course:
80-year-old male with history of hypertension, TIA, EtOH abuse
presents with STEMI s/p BMS to mid-LAD.
.
# STEMI: The patient presented with diffuse coronary artery
disease including a total occlusion of RCA, which appeared
chronic in nature, mid-LAD lesion and diffuse LCx disease. The
patient had a BMS placed in mid-LAD lesion without
complications. CE were elevated with a CK 629, MB 44, TropT
2.40. Peak CK was 629, peak troponin was 4.47.  New wall motion
abnormality consistent with LAD disease, EF [**Month (only) **] to 35%. A1C was
normal. Lipid panel with LDL 91. The patient was started on
plavix, aspirin, atorvastatin, metoprolol and lisinopril.  Due
to apical akinesis found on the echo, the patient was also
started on coumadin with a lovenox bridge.
.
# Hypertension: The patient's norvasc and doxazosin were
discontinued.
.
# Xanax abuse/distant EtOH abuse: The patient was placed on a
CIWA scale with valium as needed.  He did not require any
benzodiazepine coverage while in house.
.
# Osteoarthritis: The patient had joint pain from
osteoarthritis. He is being evaluated by orthopedics for surgery
as outpatient. He was given morphine on arrival to the floor for
pain control.  This was changed to oxycodone as per his home
regimen.

Medications on Admission:
1. Aspirin 81 mg Tablet PO DAILY
2. Lasix 20 mg PO daily(no swollen legs, SOB, CHF, per patient
due to difficult to control blood pressure)
3. Lisinopril 10 mg PO BID
4. Amlodipine 2.5 mg daily
5. Oxycodone 10mg PO q6H PRN pain
6. Ibuprofen unknown dose PRN pain
7. Remeron 45 mg q hs
8. Flexaril 5mg 1-2 tabs at hs
9. Trazadone 50 mg 1-2 tabs at hs
10. Doxazosin 1mg at hs

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*8 syringe* Refills:*2*
7. Outpatient Lab Work
Please check INR on Saturday [**2-9**] and call results to
[**Telephone/Fax (1) 98530**] pager #[**Telephone/Fax (1) 98531**]
8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
take at 4pm.
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Flexeril 5 mg Tablet Sig: 1-2 Tablets PO at bedtime.
12. Trazodone 50 mg Tablet Sig: 1-2 Tablets PO at bedtime.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute systolic Dysfunction EF 35%
Hypertension
Left Hip osteoarthritis


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


Discharge Instructions:
You had a heart attack that was caused by a blockage in the left
anterior descending artery. This blockage was fixed and a bare
metal stent was placed to prevent the artery from clotting off
again. You will need to take Plavix every day for at least one
month. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix unless Dr.
[**Last Name (STitle) **] tells you to. You will also need to start Warfarin
(coumadin) because your heart function is now weak and you are
at risk for blood clots and strokes. You will take a Lovenox
injection every day until your coumadin level is therapeutic.
Because your heart function is weak, you will need to watch for
fluid retention. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight
goes up more than 3 lbs in 1 day or 6 pounds in 3 days.
.
Medication changes:
1. Stop taking norvasc and doxazosin
2. Increase aspirin to 325 mg
3. Start taking Atrovastatin (Lipitor) to lower your cholesterol
4. Start taking Clopidogrel (Plavix) to keep the stent open
5. Decrease Lisinopril to 2.5 mg daily
6. Start taking Warfarin (coumadin) to prevent blood clots. You
will need to check your coumadin level (INR) frequently.
7. Start Metoprolol to prevent another heart attack and lower
your heart rate.
8. Start taking Lovenox to prevent blood clots until the
Warfarin starts to work. You can stop taking this when your INR
is > 2.0.

Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] A. Phone: [**Telephone/Fax (1) 1701**] Date/Time: Wednesday
[**2-13**] at 9:00am.
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 7960**] Date/Time:
.
Mark [**Doctor Last Name 2257**] Phone: [**Telephone/Fax (1) 98532**] Date/Time: [**2-19**] at 4:40pm
at [**Location 1268**] [**Hospital1 **] Site



Completed by:[**2143-2-10**]
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute combined systolic and diastolic heart failure,Coronary atherosclerosis of native coronary artery,Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of bladder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension'}


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: STEMI

PRESENT ILLNESS: 80-year-old male with history of hypertension, TIA, EtOH abuse
presents from orthopedics preop for hip surgery with EKG changes
concerning STEMI.
.
The patient was in his usual state of health until a couple
weeks prior to presentation. At that time he had intermittent
"fleeting" upper chest burning, which radiation to the jaw,
worse with exertion and quickly improved with rest. Over the
last 2 days the patient states the burning discofort has gotten
worse. He attributed the pain to "heartburn" although denies
prior symptoms of GERD and there was no relationship to eating.
He took prilosec without relief. He also notes fatigue and
insomnia. He denies nausea, vomiting, diaphoresis, or SOB. He
also notes some left scapular pain "twinges" associated with
movement during these episodes.
.
In the ED a code STEMI was called. The patient was given 600mg
PO plavix, heparin bolus and gtt, aspirin and atorvastatin. In
the cath lab they found a chronically occluded RCA, mid-LAD
lesion treated with BMS, LCx with moderate disease. The patient
was admitted to the CCU.
.
On review of systems: (-) chest pain, dyspnea on exertion,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, presyncope, stroke, DVT, PE, myalgias,
cough, hemoptysis, melena, hematochezia, fevers, chills.
(+) TIA, OA

MEDICAL HISTORY: 1. Hypertension
2. TIA - 22 years prior - slurred speech
3. Bladder CA - s/p TURP
4. Renal mass - stable cyst
5. Depression - 22 years, since wife died
6. Macular degeneration
7. EtOH abuse, distant past
8. Xanax abuse, distant past
9. Osteoarthritis - L hip pain, secondary to car accident 21
years ago
.

MEDICATION ON ADMISSION: 1. Aspirin 81 mg Tablet PO DAILY
2. Lasix 20 mg PO daily(no swollen legs, SOB, CHF, per patient
due to difficult to control blood pressure)
3. Lisinopril 10 mg PO BID
4. Amlodipine 2.5 mg daily
5. Oxycodone 10mg PO q6H PRN pain
6. Ibuprofen unknown dose PRN pain
7. Remeron 45 mg q hs
8. Flexaril 5mg 1-2 tabs at hs
9. Trazadone 50 mg 1-2 tabs at hs
10. Doxazosin 1mg at hs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T= 98.3...BP=142/77...HR=100...RR=15-25...O2 sat=100%  on 3L
GENERAL: WDWN in NAD. Oriented x3. 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: deceased liver cancer
Father: deceased MI - age - 60-years-old
Brother: deceased renal cell carcinoma
Children: x3, healthy

SOCIAL HISTORY: Lives alone, oldest daughter lives downstairs. Formerly worked
as mechanic for [**Company 2318**].
-Tobacco history: 50 pack year history, quit 30 days ago
-ETOH: Denies, history of heavy drinking, last drink 10 years
ago
-Illicit drugs: Xanax abuse 

### Response:
{'Acute myocardial infarction of anterolateral wall, initial episode of care,Acute combined systolic and diastolic heart failure,Coronary atherosclerosis of native coronary artery,Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Other chronic pulmonary heart diseases,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of bladder,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified essential hypertension'}
