CHIEF COMPLAINT: RCA dissection

PRESENT ILLNESS: 45yo Spanish-speaking woman w/ HTN, DM2, anxiety and seizure
disorder who presented to her PCP w/ chest pain. An EKG was doen
in clinic and was concerning for TW inversions in V5-V6 and she
was transferred to the ED for possible MI. Her chest pain was
relieved by nitro and she was admitted for r/o MI. She has
already had multiple negative stress tests, so the decision was
to go to cath to definitively rule-out coronary artery disease.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 DM w/ A1c of 9
- Depression/anxiety
- Hyponatremia, attributed to polydipsia and diuretic use
- Seizure disorder - on Depakote and Keppra?
- s/p hysterectomy

MEDICATION ON ADMISSION: Lantus 80u HS
Lisinopril (Patient has two prescriptions 40mg once a day and
40mg [**Hospital1 **])
Novolog 15u TID
Ativan 0.5mg QHS
Magnesium Oxide 400mg QD
Metformin 1000 MG [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Vitamin D 400U daily
Lovastatin 20mg QD
Asprin 81mg QD
Lasix 20mg Daily
Naprosyn 500mg [**Hospital1 **]
Depaktoe ER 1000mg [**Hospital1 **] (confirmed with Neurologist)
Risperdal 2mg QHS
Keppra 1000mg [**Hospital1 **] (confirmed with Neurologist)
Detrol 2mg Daily
Primidone 100mg [**Hospital1 **] (confirmed with Neurologist)
Albuterol MDI 2 puffs PRN wheezing

ALLERGIES: Penicillins / Fexofenadine

PHYSICAL EXAM: Admission Exam:
VS: T=97.6 BP=100/70 in both arms HR=95 RR= O2 sat= 93%RA
GENERAL: Moderatly obese spanish speaking woman diaphoretic in
moderate distress. Oriented x3.
HEENT: NCAT. Sclera anicteric. Pupils pin point but reactive.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft nontender
EXTREMITIES: No femoral bruits.
SKIN: Stasis dermatitis. No ulcers or scars.
Right: R 2+ DP 2+
Left: R: not palpable [**12-21**] pressure dressing in place. DP 2+

FAMILY HISTORY: Aunt with unknown cancer

SOCIAL HISTORY: -Tobacco history: none
-ETOH: none
-Illicit drugs: none
Lives with her husband and daughter. [**Name (NI) **] by a VNA daily.
Acute myocardial infarction of unspecified site, initial episode of care,Dissection of coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Anxiety state, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Sinoatrial node dysfunction,Percutaneous transluminal coronary angioplasty status
AMI NOS, initial,Dissection cor artery,Accidental op laceration,Hyposmolality,Acute kidney failure NOS,Abn react-cardiac cath,Accid in resident instit,Hypertension NOS,DMII wo cmp nt st uncntr,Long-term use of insulin,Anxiety state NOS,Epilep NOS w/o intr epil,Sinoatrial node dysfunct,Status-post ptca
Admission Date:  [**2157-10-3**]              Discharge Date:   [**2157-10-7**]

Date of Birth:  [**2111-10-28**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Fexofenadine

Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
RCA dissection

Major Surgical or Invasive Procedure:
Intra Aortic Balloon Pump- placed in OSH, removed here at [**Hospital1 18**]


History of Present Illness:
45yo Spanish-speaking woman w/ HTN, DM2, anxiety and seizure
disorder who presented to her PCP w/ chest pain. An EKG was doen
in clinic and was concerning for TW inversions in V5-V6 and she
was transferred to the ED for possible MI. Her chest pain was
relieved by nitro and she was admitted for r/o MI. She has
already had multiple negative stress tests, so the decision was
to go to cath to definitively rule-out coronary artery disease.

.
Catheterization revealed no left main disease or LAD disease.
LCX seperate ostium adjacent to RCA ostium, RCA non-obstructive
proximal plaque. Following Cath she developed chest pain and
reported ST elevations. Repeat cath revealed spiral dissection
to distal vessels with proximal occlusion. She reportedly became
bradycardic to the 30's and received 0.75 mg atropine. A stent
was deployed across the distention with likely jailing off of
the acute marginal branch. An IABP was placed to improve
myocardial oxygenation and she was transfferred to [**Hospital1 18**] for
managemetn of IABP.
.
On arrival she complained of chest pain with radiation to the
back.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 DM w/ A1c of 9
- Depression/anxiety
- Hyponatremia, attributed to polydipsia and diuretic use
- Seizure disorder - on Depakote and Keppra?
- s/p hysterectomy


Social History:
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Lives with her husband and daughter. [**Name (NI) **] by a VNA daily.


Family History:
Aunt with unknown cancer

Physical Exam:
Admission Exam:
VS: T=97.6 BP=100/70 in both arms HR=95 RR= O2 sat= 93%RA
GENERAL: Moderatly obese spanish speaking woman diaphoretic in
moderate distress. Oriented x3.
HEENT: NCAT. Sclera anicteric. Pupils pin point but reactive.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft nontender
EXTREMITIES: No femoral bruits.
SKIN: Stasis dermatitis. No ulcers or scars.
Right: R 2+ DP 2+
Left: R: not palpable [**12-21**] pressure dressing in place. DP 2+


Pertinent Results:
Echo:
Suboptimal image quality.The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). There is no ventricular septal defect.
The RV free wall appears hypokinetic (the apex is hyperdynamic).
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to high
cardiac output. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is a minimally increased gradient
consistent with trivial mitral stenosis. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: RV infarction? If indicated, a repeat study with
echo contrast may better assess basl to mid RV free wall
function

Repeat Echo few days later:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The tricuspid valve leaflets are
mildly thickened. There is borderline pulmonary artery systolic
hypertension. There is a small pericardial effusion. The
effusion appears circumferential. There are no echocardiographic
signs of tamponade. Echocardiographic signs of tamponade may be
absent in the presence of elevated right sided pressures.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional left ventricular systolic
function. Dilated RV with free wall hypokinesis. The apex of the
right ventricle has preserved function. There is pressure/volume
overload of the right ventricle. The estimated pulmonary artery
pressures are only mildly elevated - may be UNDERestimated.
Small pericardial effusion located mostly posterior to the left
ventricle without tamponade physiology.

Brief Hospital Course:
48 YO woman with multiple cardiac risk factors s/p cardiac cath
to R/O CAD complicated by RCA dissection and likely jailing of
acute marginal branch in setting of placement of 3 stents,
transfered to [**Hospital1 18**] CCU with clinical picture concerning for
acute MI of the RV.
.
# Coronaries/Chest pain: Symptoms and EKG findings (STE in
Inferior leads III>II with STE in RV leads is consistent)
consistent with RV infarct likely proximal RCA. Pt's RCA
dissection was secondary iatrogenic causes which temporarily
disrutped flow through RCA. Three stents were placed which
jailed off some of the braching arteries resulting in
post-procedure troponin bump. Troponin peaked at 1.28 and
trended down. Pt transfered here on IABP and heparin drip. IABP
was weaned. Pt given plavix 75mg daily, ASA 325mg daily,
lovastatin 20mg daily for medical management of her CAD. Will
follow with cardiologist outpatient.
.
# PUMP: Initially on IABP which was weaned. Pt's EF is >55%.
Echo showed dilated RV with free wall hypokinesis. Apex has
preserved function.
.
# RHYTHM: Initially had Junctional escape rhythm and then atrial
escape rhythm likely secondary to ischemia of sinus node from
jailing off of proximal RCA branches. Asymptomatic and stable
hemodynamically.
.
# Hyperkalemia: Initially had hyperkalemia on transfer with some
T-wave elevations. Was given kayexelate and insulin with
stabalization of potassium. No further hyperkalemia.
.
# Seizure disorder: Spoke with outpatient neurologist and
patient was given her outpatient seizure regimen.
.
# DM: ISS and held metformin
.
# Dyslipidemia: Continued statin
.
# Anemia: Likely chronic in nature since pt is on ferrous
sulfate at home. It was stable at 28 range. Asymptomatic.


Medications on Admission:
Lantus 80u HS
Lisinopril (Patient has two prescriptions 40mg once a day and
40mg [**Hospital1 **])
Novolog 15u TID
Ativan 0.5mg QHS
Magnesium Oxide 400mg QD
Metformin 1000 MG [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Vitamin D 400U daily
Lovastatin 20mg QD
Asprin 81mg QD
Lasix 20mg Daily
Naprosyn 500mg [**Hospital1 **]
Depaktoe ER 1000mg [**Hospital1 **] (confirmed with Neurologist)
Risperdal 2mg QHS
Keppra 1000mg [**Hospital1 **] (confirmed with Neurologist)
Detrol 2mg Daily
Primidone 100mg [**Hospital1 **] (confirmed with Neurologist)
Albuterol MDI 2 puffs PRN wheezing


Discharge Medications:
1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
2. Lantus 100 unit/mL Solution Sig: Eighty (80) units
Subcutaneous at bedtime.
3. Novolog 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous three times a day: Before meals.
4. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
5. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. ferrous sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
8. lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Outpatient Lab Work
Please check Chem-7 on Monday [**2157-10-10**] with results to Dr.
[**Last Name (STitle) **],KIAME J [**Telephone/Fax (1) 63099**]
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. divalproex 500 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO BID (2 times a day).
15. risperidone 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
16. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. primidone 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
18. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
19. tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).


Discharge Disposition:
Home With Service

Facility:
Multicultural Home Care

Discharge Diagnosis:
ST Elevation Myocardial Infarction
Seizure disorder
Hypertension
Acute Kidney Injury


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


Discharge Instructions:
You had a cardiac catheterization at [**Hospital6 3105**]
and one of your heart arteries was damaged and needed to be
fixed with a bare etal stent. You had some damage to the right
side of your heart that should get better over time. You will be
on a new medicine called Clopidogrel or Plavix and your will
need to increase your aspirin to 325 mg daily from 81 mg daily.
It is extremely important to take Aspirin and Plavix every day,
no not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix and aspirin unless
Dr. [**Last Name (STitle) **] tells you it is OK. You will need to see Dr.
[**Last Name (STitle) 66153**] in 1 week and Dr. [**Last Name (STitle) **] in 1 month. No lifting more
than 10 pounds for one week. Please watch the right groin area
for any increasing pain or bruising or any bleeding. Call Dr.
[**Last Name (STitle) **] if you notice any of these changes.

Medication changes:
1. Start Plavix to keep the stent in your heart artery from
clotting off
2. Increase Aspirin to 325 mg daily
3. Start taking Norvasc to control your blood pressure
4. Do not take your Lisinopril or naprosyn until Dr. [**Last Name (STitle) 66153**]
tells you it is ok to start.
5. You will need to have some blood drawn on Monday to check
your kidney function.
.
Make sure to follow up outpatient with Dr. [**Last Name (STitle) 66153**] to get a
sleep study for possible sleep apnea.

Followup Instructions:
Name: [**Last Name (STitle) **],KIAME J
Address: [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 66038**]
Phone: [**Telephone/Fax (1) 63099**]
*Please call your PCP to book an appointment within 1 week.

Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital 46644**] MEDICAL ASSOCIATES,LLC
Phone: [**Telephone/Fax (1) 63259**]
When: Wednesday, [**11-9**], 1PM
{'Acute myocardial infarction of unspecified site, initial episode of care,Dissection of coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Anxiety state, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Sinoatrial node dysfunction,Percutaneous transluminal coronary angioplasty status'}


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: RCA dissection

PRESENT ILLNESS: 45yo Spanish-speaking woman w/ HTN, DM2, anxiety and seizure
disorder who presented to her PCP w/ chest pain. An EKG was doen
in clinic and was concerning for TW inversions in V5-V6 and she
was transferred to the ED for possible MI. Her chest pain was
relieved by nitro and she was admitted for r/o MI. She has
already had multiple negative stress tests, so the decision was
to go to cath to definitively rule-out coronary artery disease.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Type 2 DM w/ A1c of 9
- Depression/anxiety
- Hyponatremia, attributed to polydipsia and diuretic use
- Seizure disorder - on Depakote and Keppra?
- s/p hysterectomy

MEDICATION ON ADMISSION: Lantus 80u HS
Lisinopril (Patient has two prescriptions 40mg once a day and
40mg [**Hospital1 **])
Novolog 15u TID
Ativan 0.5mg QHS
Magnesium Oxide 400mg QD
Metformin 1000 MG [**Hospital1 **]
Ranitidine 150mg [**Hospital1 **]
Ferrous sulfate 325mg daily
Vitamin D 400U daily
Lovastatin 20mg QD
Asprin 81mg QD
Lasix 20mg Daily
Naprosyn 500mg [**Hospital1 **]
Depaktoe ER 1000mg [**Hospital1 **] (confirmed with Neurologist)
Risperdal 2mg QHS
Keppra 1000mg [**Hospital1 **] (confirmed with Neurologist)
Detrol 2mg Daily
Primidone 100mg [**Hospital1 **] (confirmed with Neurologist)
Albuterol MDI 2 puffs PRN wheezing

ALLERGIES: Penicillins / Fexofenadine

PHYSICAL EXAM: Admission Exam:
VS: T=97.6 BP=100/70 in both arms HR=95 RR= O2 sat= 93%RA
GENERAL: Moderatly obese spanish speaking woman diaphoretic in
moderate distress. Oriented x3.
HEENT: NCAT. Sclera anicteric. Pupils pin point but reactive.
NECK: Supple with JVP of 11 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft nontender
EXTREMITIES: No femoral bruits.
SKIN: Stasis dermatitis. No ulcers or scars.
Right: R 2+ DP 2+
Left: R: not palpable [**12-21**] pressure dressing in place. DP 2+

FAMILY HISTORY: Aunt with unknown cancer

SOCIAL HISTORY: -Tobacco history: none
-ETOH: none
-Illicit drugs: none
Lives with her husband and daughter. [**Name (NI) **] by a VNA daily. 

### Response:
{'Acute myocardial infarction of unspecified site, initial episode of care,Dissection of coronary artery,Accidental puncture or laceration during a procedure, not elsewhere classified,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Anxiety state, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Sinoatrial node dysfunction,Percutaneous transluminal coronary angioplasty status'}
