CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 83F with history of hypertension admitted to OSH for 2 weeks of
chest pain radiating to back, neck and arm who is not
transferred to [**Hospital1 **] for further evaluation and possible cardiac
catheterization. Pt states that the pain began about 2 week ago.
It has been intermittent with paroxyms lasting 5-10 minutes. Pt
states that the onset is gradual and that the pain increases
over the 5-10 minutes to a maximum of [**11-4**]. She had taken ASA
at home with some relief of her symptoms and NTG at the OSH
which relieved her symptoms. The pain seems to be getting worse
over the last 2 weeks. At times it takes her breath away. She
does state that the pain is the same as reflux symptoms that she
has had in the past, though this pattern and presenation s clear
more persistent and severe. The patient notes that her chest and
abdomen turn red when she is having the pain and that her blood
pressure shoots up to the 190s from a baseline in the 150-160s.
She denies palpitations but does note dyspnea on exertion which
has been progressive since her stroke six years ago, likely due
to a significant decrease in her activity level. EKGs at OSH
unchanged from baseline but does have significant LVH with ST
changed. Trop at OSH equivocal at .04. Pt started on a heaprin
gtt prior to transfer.

MEDICAL HISTORY: Stroke 6 years ago with residual right-sided hemiparesis
Hypertension
Macular Degeneration
Chronic Renal Failure Baseline Cr: 1.6

MEDICATION ON ADMISSION: Home Medications:
Aggrenox 20/100 [**Hospital1 **]
Citalopram 20mg daily
Lipitor 10mg daily
Diovan 320 mg daily
Metoprolol 100 mg daily
HCTZ 25mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:
VS: T= 98.1 BP= 158/65 HR= 75 RR= 18 O2 sat= 95% RA
GENERAL: Well-appearing, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murumur. 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.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+

FAMILY HISTORY: Brother multiple stents. Sister valve replacement

SOCIAL HISTORY: -Tobacco history: Smoked on Saturday nights for 50 years
-ETOH: 1 glass of white wine with dinner nightly
-Illicit drugs: No
Aortic valve disorders,Subendocardial infarction, initial episode of care,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified
Aortic valve disorder,Subendo infarct, initial,Late ef-hemplga side NOS,Crnry athrscl natve vssl,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS
Admission Date:  [**2191-11-11**]              Discharge Date:   [**2191-11-24**]

Date of Birth:  [**2108-8-10**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
[**2191-11-18**] - CABGx3(Left internal mammary artery->Left anterior
descending artery, Vein graft->Obtuse marginal artery, Vein
graft->Posterior descending artery)
[**2191-11-14**] - Cardiac Cathetriztaion


History of Present Illness:
83F with history of hypertension admitted to OSH for 2 weeks of
chest pain radiating to back, neck and arm who is not
transferred to [**Hospital1 **] for further evaluation and possible cardiac
catheterization. Pt states that the pain began about 2 week ago.
It has been intermittent with paroxyms lasting 5-10 minutes. Pt
states that the onset is gradual and that the pain increases
over the 5-10 minutes to a maximum of [**11-4**]. She had taken ASA
at home with some relief of her symptoms and NTG at the OSH
which relieved her symptoms. The pain seems to be getting worse
over the last 2 weeks. At times it takes her breath away. She
does state that the pain is the same as reflux symptoms that she
has had in the past, though this pattern and presenation s clear
more persistent and severe. The patient notes that her chest and
abdomen turn red when she is having the pain and that her blood
pressure shoots up to the 190s from a baseline in the 150-160s.
She denies palpitations but does note dyspnea on exertion which
has been progressive since her stroke six years ago, likely due
to a significant decrease in her activity level. EKGs at OSH
unchanged from baseline but does have significant LVH with ST
changed. Trop at OSH equivocal at .04. Pt started on a heaprin
gtt prior to transfer.

On review of systems, s/he denies has a prior history of stroke.
She denies recent fevers, chills or rigors. All of the other
review of systems were negative except for depression and
occational swelling of her right lower extremity.

On arrival to the floor, vitals 98.1 196/86 75 18 99%RA. Pt was
having 8/10 chest pain. EKG was inchanged from baseline and pain
responded to 2 NTG's.


Past Medical History:
Stroke 6 years ago with residual right-sided hemiparesis
Hypertension
Macular Degeneration
Chronic Renal Failure Baseline Cr: 1.6

Social History:
-Tobacco history: Smoked on Saturday nights for 50 years
-ETOH: 1 glass of white wine with dinner nightly
-Illicit drugs: No

Family History:
Brother multiple stents. Sister valve replacement


Physical Exam:
Admission Exam:
VS: T= 98.1 BP= 158/65 HR= 75 RR= 18 O2 sat= 95% RA
GENERAL: Well-appearing, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murumur. 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.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+


Pertinent Results:
C. Cath [**2191-11-14**]
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with mild-moderate LMCA
CAD.
2. Moderate pulmonary arterial hypertension.
3. Moderate-severe LV diastolic heart failure.
4. Severe aortic stenosis ([**Location (un) 109**]>0.7 given known AI)
5. Likely significant mitral regurgitation given prominent
(almost
giant) PCW V waves

CT Chest
IMPRESSIONS:
1. Vascular calcifications involve a portion of the ascending
aorta as
detailed above, its major branches, and the coronary arteries.
2. Aortic valve and mitral annular calcifications.
3. Small right and minimal left pleural effusion, without
evidence of
pulmonary edema.
4. Subpleural right middle lobe nodules measure up to 5 mm. In a
patient
without strong risk factors for intrathoracic malignancy,
follow-up CT would
be recommended in 12 months; if there are strong risk factors,
initial follow-
up in [**7-7**] months time would be recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**]
guidelines.
5. Calcified lung nodules consistent with prior granulomatous
disease.
6. Small-to-moderate hiatal hernia, with probable redundant
mucosa.
7. Colonic diverticulosis.
8. Left renal calculus.

Carotid U/S
IMPRESSION:
1. No signal significant ICA stenosis on either side.
2. Antegrade flow in both vertebral arteries.

ECHO [**2191-11-12**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 70%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. There are focal calcifications
in the aortic arch. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The left ventricular inflow
pattern suggests impaired relaxation. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

[**2191-11-24**] 05:25AM BLOOD WBC-10.2 RBC-3.35* Hgb-10.6* Hct-30.0*
MCV-90 MCH-31.5 MCHC-35.2* RDW-14.4 Plt Ct-305#
[**2191-11-24**] 05:25AM BLOOD Glucose-104 UreaN-49* Creat-1.4* Na-144
K-3.6 Cl-106 HCO3-25 AnGap-17

Brief Hospital Course:
Mrs. [**Known lastname 62993**] was admitted to the [**Hospital1 18**] on [**2191-11-11**] for further
management of her chest pain. Aspirin, beta blockade, a statin
and heparin were continued. She underwent a cardiac
catheterization which revealed severe three vessel coronary
artery disease and severe aortic stenosis. Given the severity of
her disease, the cardiac surgical service was consulted for
surgical management. Mrs. [**Known lastname 62993**] was worked-up in the usual
preoperative manner including a carotid duplex ultrasound which
showed no significant stenosis of the bilateral internal carotid
arteries. A dental consult was obtained for oral clearance for
surgery. After obtaining a panorex of her teeth, no evidence of
oral infection was noted which would contraindicate valve
surgery. She was transfused with packed red blood cells for
preop anemia. She developed ST changes and hypotension and was
transferred to the cardiac intensive care unit for monitoring.
On [**2191-11-18**], Mrs. [**Known lastname 62993**] was taken to the operating room where
she underwent coronary artery bypass grafting to three vessels
and an aortic valve replacement using a 21mm [**Company **] mosaic
ultra porcine valve. Please see operative note for details.
Postoperatively she was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, she awoke
neurologically intact and was extubated. She was slowly weaned
off her pressors and iontropes. Aspirn, a statin and
betablockade were rsuemd. On postoperative day two, she was
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. The physical
therapy service was consulted for assistance with her
postoperative strength and mobility. The patient was discharged
in good condition to rehab on POD 6.

Medications on Admission:
Home Medications:
Aggrenox 20/100 [**Hospital1 **]
Citalopram 20mg daily
Lipitor 10mg daily
Diovan 320 mg daily
Metoprolol 100 mg daily
HCTZ 25mg daily


Discharge Medications:
1. Furosemide 10 mg/mL Solution Sig: Two (2)  Injection TID (3
times a day).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three
times a day.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
AS/CAD s/p CABGx2/AVR
CVA
HTN
Depression
Macular degeneration


Discharge Condition:
good


Discharge Instructions:
1)  Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2)  Report any fever greater then 100.5.
3)  Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4)  No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry.  Please shower daily.  No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**2-27**] weeks.
Please follow-up with Dr. [**Last Name (STitle) 8579**] (cardiology) in 2 weeks ([**Apartment Address(1) 80022**] [**Location (un) **], [**Numeric Identifier 80023**] Phone:
[**Telephone/Fax (1) 23882**])
Please call all providers for appointments.



Completed by:[**2191-11-24**]
{'Aortic valve disorders,Subendocardial infarction, initial episode of care,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}


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: 83F with history of hypertension admitted to OSH for 2 weeks of
chest pain radiating to back, neck and arm who is not
transferred to [**Hospital1 **] for further evaluation and possible cardiac
catheterization. Pt states that the pain began about 2 week ago.
It has been intermittent with paroxyms lasting 5-10 minutes. Pt
states that the onset is gradual and that the pain increases
over the 5-10 minutes to a maximum of [**11-4**]. She had taken ASA
at home with some relief of her symptoms and NTG at the OSH
which relieved her symptoms. The pain seems to be getting worse
over the last 2 weeks. At times it takes her breath away. She
does state that the pain is the same as reflux symptoms that she
has had in the past, though this pattern and presenation s clear
more persistent and severe. The patient notes that her chest and
abdomen turn red when she is having the pain and that her blood
pressure shoots up to the 190s from a baseline in the 150-160s.
She denies palpitations but does note dyspnea on exertion which
has been progressive since her stroke six years ago, likely due
to a significant decrease in her activity level. EKGs at OSH
unchanged from baseline but does have significant LVH with ST
changed. Trop at OSH equivocal at .04. Pt started on a heaprin
gtt prior to transfer.

MEDICAL HISTORY: Stroke 6 years ago with residual right-sided hemiparesis
Hypertension
Macular Degeneration
Chronic Renal Failure Baseline Cr: 1.6

MEDICATION ON ADMISSION: Home Medications:
Aggrenox 20/100 [**Hospital1 **]
Citalopram 20mg daily
Lipitor 10mg daily
Diovan 320 mg daily
Metoprolol 100 mg daily
HCTZ 25mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:
VS: T= 98.1 BP= 158/65 HR= 75 RR= 18 O2 sat= 95% RA
GENERAL: Well-appearing, NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. No xanthalesma.
NECK: No JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. III/VI systolic murumur. 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.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+
Left: DP 1+

FAMILY HISTORY: Brother multiple stents. Sister valve replacement

SOCIAL HISTORY: -Tobacco history: Smoked on Saturday nights for 50 years
-ETOH: 1 glass of white wine with dinner nightly
-Illicit drugs: No 

### Response:
{'Aortic valve disorders,Subendocardial infarction, initial episode of care,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Coronary atherosclerosis of native coronary artery,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}
