CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: 78F presented to OSH last week with c/o chest pain.  She ruled
in for NSTEMI with troponin peaking at 13ng/mL.  Cardiac cath
showed severe two vessel coronary artery disease with a 90%
lesion in a heavily calcified LAD and total occlusion on the
right.  The PDA is supplied via collaterals from the LAD,
therefore stenting of the LAD was considered high risk.  She is
transferred for CABG evaluation.  She has been taking Plavix.
Additionally, she presented to the ED with new onset rapid
atrial fibrillation, which was rate controlled with IV
Diltiazem, digoxin and Lopressor.  Initial hematocrit was 30%,
GI was consulted and recommended follow up as an outpatient
following resolution of
cardiac issues.

MEDICAL HISTORY: Coronary Artery Disease
Mitral Valve Prolapse
chronic diastolic heart failure
Diabetes Mellitus
Hypertension
Hypothyroidism

MEDICATION ON ADMISSION: on admission to OSH:
ISMN
Lasix
Lipitor
Atenolol
levothyroxine
lisinopril
metformin
aspirin
loratadine

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: 86  Resp: 16  O2 sat: 98%RA
B/P  Right: 117/61    Left:
Height:  65"   Weight: 156lb

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives with: alone, has 4 children
Cigarettes: Smoked no [x] yes
Other Tobacco use: none
Mitral valve disorders,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hematoma complicating a procedure,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other iatrogenic hypotension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Mitral valve disorder,Subendo infarct, initial,Acute kidney failure NOS,Urin tract infection NOS,Hematoma complic proc,Chr diastolic hrt fail,Ac posthemorrhag anemia,Crnry athrscl natve vssl,Atrial fibrillation,Iatrogenc hypotnsion NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Hypothyroidism NOS,Exam-clincal trial,Abn react-anastom/graft,Abn react-cardiac cath
Admission Date:  [**2190-8-9**]              Discharge Date:   [**2190-8-23**]

Date of Birth:  [**2111-9-16**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain


Major Surgical or Invasive Procedure:
[**2190-8-12**] Cardioversion

[**2190-8-17**] Coronary artery bypass graft x1 (left internal mammary
artery > left anterior descending) Mitral valve repair (28 mm
annuloplasty ring)


History of Present Illness:
78F presented to OSH last week with c/o chest pain.  She ruled
in for NSTEMI with troponin peaking at 13ng/mL.  Cardiac cath
showed severe two vessel coronary artery disease with a 90%
lesion in a heavily calcified LAD and total occlusion on the
right.  The PDA is supplied via collaterals from the LAD,
therefore stenting of the LAD was considered high risk.  She is
transferred for CABG evaluation.  She has been taking Plavix.
Additionally, she presented to the ED with new onset rapid
atrial fibrillation, which was rate controlled with IV
Diltiazem, digoxin and Lopressor.  Initial hematocrit was 30%,
GI was consulted and recommended follow up as an outpatient
following resolution of
cardiac issues.

Past Medical History:
Coronary Artery Disease
Mitral Valve Prolapse
chronic diastolic heart failure
Diabetes Mellitus
Hypertension
Hypothyroidism


Social History:
Lives with: alone, has 4 children
Cigarettes: Smoked no [x] yes
Other Tobacco use: none


Family History:
non contributory

Physical Exam:
Pulse: 86  Resp: 16  O2 sat: 98%RA
B/P  Right: 117/61    Left:
Height:  65"   Weight: 156lb

General: NAD, WGWN elderly female
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR []  Irregular [x]  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema [] trace_
Varicosities: minor
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: 2+  Left:2+
DP           Right: 1+  Left:1+
PT           [**Name (NI) 167**]: 1+  Left:1+
Radial       Right: 2+  Left:2+

Carotid Bruit   none

Pertinent Results:
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-No spontaneous echo contrast or thrombus is seen in the body of
the right atrium or the right atrial appendage.
-No atrial septal defect is seen by 2D or color Doppler.
-The coronary sinus is mildly dilated (diameter 1.1cm). No
bubbles/saline noted in CS during interrogation for persistent
LSVC.
-Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is mildly depressed (LVEF= 40-50 %).
-There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
-The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic regurgitation is seen.
-The mitral valve leaflets are severely thickened/deformed.
There is severe restriction of the posterior mitral valve
leaflet. There is moderate thickening of the mitral valve
chordae attached to the anterior mitral leaflet. The mitral
regurgitation vena contracta is >=0.7cm. Severe (4+) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect).
-The tricuspid valve leaflets are mildly thickened.
-There is mild pulmonary artery systolic hypertension.
-There is no pericardial effusion.

Dr. [**Last Name (STitle) **] was notified of the results at the time of the
study.

POSTBYPASS: On phenylephrine, a pacing briefly. Prior to weaning
from cpb, there was moderate to severe mitral regurgitation,
which reduced to 1+ off bypass. Two small jets of mitral
regurgitation were seen. Dr. [**First Name (STitle) 6507**] was able to image the
regurgitation using 3-D. LV fuction was normal. The annuloplasty
ring was well-seated without rocking and with only a small
perivalvular leak. The AI remains 1+ and the aortic contour is
normal post decannulation.
  I certify that I was present for this procedure in compliance
with HCFA regulations.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2190-8-17**] 13:42

[**2190-8-21**] 08:00AM BLOOD WBC-12.0* RBC-3.49* Hgb-10.7* Hct-31.0*
MCV-89 MCH-30.7 MCHC-34.6 RDW-14.9 Plt Ct-179
[**2190-8-20**] 06:20AM BLOOD PT-17.2* INR(PT)-1.5*
[**2190-8-21**] 08:00AM BLOOD Glucose-166* UreaN-24* Creat-0.8 Na-136
K-4.0 Cl-98 HCO3-31 AnGap-11
[**2190-8-21**] 08:00AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0
[**2190-8-23**] 06:20AM BLOOD WBC-10.8 RBC-3.17* Hgb-9.6* Hct-27.9*
MCV-88 MCH-30.2 MCHC-34.3 RDW-14.4 Plt Ct-234
[**2190-8-23**] 06:20AM BLOOD PT-35.0* INR(PT)-3.5*
[**2190-8-22**] 06:40AM BLOOD PT-39.5* INR(PT)-4.0*
[**2190-8-21**] 07:11PM BLOOD PT-27.7* PTT-27.2 INR(PT)-2.7*
[**2190-8-21**] 02:43PM BLOOD PT-62.2* INR(PT)-6.9*
[**2190-8-21**] 01:10AM BLOOD PT-55.4* INR(PT)-6.0*
[**2190-8-20**] 06:20AM BLOOD PT-17.2* INR(PT)-1.5*
[**2190-8-23**] 06:20AM BLOOD UreaN-23* Creat-1.0 Na-140 K-4.1 Cl-98
[**2190-8-22**] 06:40AM BLOOD Glucose-120* UreaN-24* Creat-0.8 Na-137
K-3.8 Cl-97 HCO3-33* AnGap-11

Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation.
Her lisinopril was stopped for creatinine elevation of 1.6 up
from 1.1 on labs from outside hospital - noted for acute kidney
injury on admission.  Her creatinine was monitored
preoperatively and progressively trended down.  Additionally on
admission labs, she  had urine culture that revealed E coli that
was treated with ciprofloxacin.
She was continued on heparin for atrial fibrillation, and
continued on digoxin and diltiazem for rate management.  Then on
[**2190-8-12**] she underwent transesophageal echocardiogram to
evaluate valve and rule out any clot prior to cardioversion.
She underwent cardioversion and converted to sinus rhythm.  She
was started on amiodarone and digoxin was stopped, and continued
on heparin until right groin presented with hematoma.  She
underwent ultrasound that ruled out pseudo aneurysm and vascular
surgery was consulted.  She did have drop in hct from admission
at 32 down to 24.8 and was transfused with packed red blood
cells, and responded appropriately.  Her groin remained stable
until she was brought to the operating room on [**8-17**] for coronary
artery bypass graft and mitral valve repair surgery.
See operative report for further details.

Post operatively she was transferred to the intensive care unit
for management.  She had post operative bleeding that was
treated with blood products with improvement.  She remained
intubated overnight on propofol and neosynephrine for blood
pressure management.  The morning of postoperative day one she
was weaned from sedation, awoke neurologically intact and was
extubated without complication.  She was started on lasix for
diuresis but remained on neosynephrine until that afternoon, of
which then betablockers were started.  She remained in the
intensive care unit for monitoring and on post operative day two
was restarted on amiodarone for preoperative atrial fibrillation
and coumadin.  She continued to improve and was ready for
transfer to the floor.  Physical therapy worked with her on
strength and mobility.  Chest tubes and pacing wires were
removed without complication.

She is to be discharged to rehab on telemetry with history of
preoperative atrial fibrillation as well as IV lasix with
significant post operative residual edema.

***Plavix may be restarted per her cardiologist ( please check
with him prior to her discharge from rehab).Target INR for A Fib
2.0-2.5. First INR check day after discharge.
Cleared for discharge to [**Hospital3 **] in [**Location (un) 8957**] on POD 6.
All f/u appts were advised.




Medications on Admission:
on admission to OSH:
ISMN
Lasix
Lipitor
Atenolol
levothyroxine
lisinopril
metformin
aspirin
loratadine


Discharge Medications:
1. furosemide 10 mg/mL Solution Sig: Four (4)  Injection every
twenty-four(24) hours for 7 days: 40 mg IV every 24 hours for
one week; please monitor creatinine.
2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.

3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
through [**8-26**]; then 200 mg daily ongoing.
10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. warfarin 1 mg Tablet Sig: daily dosing per rehab provider
Tablet PO Once Daily at 4 PM: target INR 2.0-2.5 for A Fib.
13. insulin lispro 100 unit/mL Solution Sig: per insulin
flowsheet sliding scale as attached Subcutaneous ASDIR (AS
DIRECTED).
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Coronary artery disease s/p CABG
Mitral valve prolapse s/p MV repair
Atrial Fibrillation preoperative
Non ST elevation myocardial infarction
Acute kidney injury on transfer Cr 1.6 was 1.1 at OSH
Urinary tract infection on transfer
Right groin hematoma s/p cardiac catheterization OSH
Chronic diastolic heart failure
Diabetes Mellitus
Hypertension
Hypothyroidism


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema [**12-6**]+


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] Wednesday [**9-22**] @ 1:30 pm  [**Hospital Ward Name **] 2A
[**Telephone/Fax (1) 170**]
Cardiologist: Dr [**Last Name (STitle) 42394**] [**9-2**] @ 2:00 PM

Please call to schedule appointments with your
Primary Care Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]  in [**3-9**] weeks

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Labs: PT/INR for Coumadin ?????? indication A Fib
Goal INR 2.0-2.5
First draw [**2190-8-24**]
***please arrange for coumadin/INR f/u prior to discharge from
rehab



Completed by:[**2190-8-23**]
{'Mitral valve disorders,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hematoma complicating a procedure,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other iatrogenic hypotension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: 78F presented to OSH last week with c/o chest pain.  She ruled
in for NSTEMI with troponin peaking at 13ng/mL.  Cardiac cath
showed severe two vessel coronary artery disease with a 90%
lesion in a heavily calcified LAD and total occlusion on the
right.  The PDA is supplied via collaterals from the LAD,
therefore stenting of the LAD was considered high risk.  She is
transferred for CABG evaluation.  She has been taking Plavix.
Additionally, she presented to the ED with new onset rapid
atrial fibrillation, which was rate controlled with IV
Diltiazem, digoxin and Lopressor.  Initial hematocrit was 30%,
GI was consulted and recommended follow up as an outpatient
following resolution of
cardiac issues.

MEDICAL HISTORY: Coronary Artery Disease
Mitral Valve Prolapse
chronic diastolic heart failure
Diabetes Mellitus
Hypertension
Hypothyroidism

MEDICATION ON ADMISSION: on admission to OSH:
ISMN
Lasix
Lipitor
Atenolol
levothyroxine
lisinopril
metformin
aspirin
loratadine

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: 86  Resp: 16  O2 sat: 98%RA
B/P  Right: 117/61    Left:
Height:  65"   Weight: 156lb

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives with: alone, has 4 children
Cigarettes: Smoked no [x] yes
Other Tobacco use: none 

### Response:
{'Mitral valve disorders,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hematoma complicating a procedure,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other iatrogenic hypotension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
