CHIEF COMPLAINT: Chest pain.

PRESENT ILLNESS: 72 year old male with known CAD s/p CABG in [**2175**] (see below) and
MI/PCI in [**2187**], chronic chest wall pain, who presented to
[**Hospital 24356**] Hospital with complaints of worsening chest pain
radiating to left arm and back, associated with diaphoresis and
presyncopal symptoms.

MEDICAL HISTORY: 1. Coronary artery disease:
   a. Anterior STEMI / CABG ([**2175**])
   - LIMA to LAD
   - SVG to OM
   - SVG to PDA
   - SVG to D2
   b. Percutaneous coronary intervention ([**2177**])
   - No intervention with one occluded SVG
   c. NQWMI / Percutaneous coronary intervention ([**2187**])
   - LAD total occlusion proximally
   - LCx 90% occluded prox --> s/p stenting (3.0 x 18mm BX
Velocity)
   - RCA total occusion proximally
   - SVG --> PDA patent
   - SVG --> OM total occlusion
   - SVG --> D2 90% distal stenosis --> s/p stenting (4.0 x 18mm
BX velocity)
2. Hypertension
3. Chronic obstructive pulmonary disease
4. Gastroesophageal reflux disease: s/p Billroth II gastrectomy

MEDICATION ON ADMISSION: Atenolol 25mg daily
Captopril 12.5mg TID
Percocet PRN
ASA 81mg daily

ALLERGIES: Ampicillin

PHYSICAL EXAM: Blood pressure was 94/65 mm Hg while supine, intubated/sedated.
Pulse was 64 beats/min and regular, respiratory rate was 15
breaths/min.
Generally the patient was well developed, well nourished.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Social history is significant for current tobacco use (1 pack
every other day). There is no history of alcohol abuse. There is
no family history of premature coronary artery disease or sudden
death.
Subendocardial infarction, initial episode of care,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Bipolar disorder, unspecified,Tobacco use disorder,Constipation, unspecified,Accidents occurring in residential institution,Other iatrogenic hypotension,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Subendo infarct, initial,Chr airway obstruct NEC,Pneumonia, organism NOS,Crnry athrscl natve vssl,Esophageal reflux,Bipolar disorder NOS,Tobacco use disorder,Constipation NOS,Accid in resident instit,Iatrogenc hypotnsion NEC,Abn react-cardiac cath
Admission Date:  [**2193-4-15**]              Discharge Date:   [**2193-4-19**]

Date of Birth:  [**2121-2-13**]             Sex:   M

Service: MEDICINE

Allergies:
Ampicillin

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain.

Major Surgical or Invasive Procedure:
Cardiac cath with Cypher stent placement ([**2193-4-15**]).


History of Present Illness:
72 year old male with known CAD s/p CABG in [**2175**] (see below) and
MI/PCI in [**2187**], chronic chest wall pain, who presented to
[**Hospital 24356**] Hospital with complaints of worsening chest pain
radiating to left arm and back, associated with diaphoresis and
presyncopal symptoms.

Given ASA, NTG, heparin, plavix load, zofran, morphine,
lopressor 50 mg at OSH. Trop I up to 20; EKG showed
antero-lateral ST depressions.  Guaiac negative at the OSH.

Of note, there was a question of pulmonary infiltrate on CXR, so
patient was given CTX and azithromycin for CAP.

Past Medical History:
1. Coronary artery disease:
   a. Anterior STEMI / CABG ([**2175**])
   - LIMA to LAD
   - SVG to OM
   - SVG to PDA
   - SVG to D2
   b. Percutaneous coronary intervention ([**2177**])
   - No intervention with one occluded SVG
   c. NQWMI / Percutaneous coronary intervention ([**2187**])
   - LAD total occlusion proximally
   - LCx 90% occluded prox --> s/p stenting (3.0 x 18mm BX
Velocity)
   - RCA total occusion proximally
   - SVG --> PDA patent
   - SVG --> OM total occlusion
   - SVG --> D2 90% distal stenosis --> s/p stenting (4.0 x 18mm
BX velocity)
2. Hypertension
3. Chronic obstructive pulmonary disease
4. Gastroesophageal reflux disease: s/p Billroth II gastrectomy

5. Bipolar disorder
6. s/p diskectomy
7. s/p carotid endarterectomy
8. Chronic chest wall pain, followed at the [**First Name4 (NamePattern1) 1193**] [**Last Name (NamePattern1) 1194**]
management center
9. Splanchnic neuropathy s/p spinal cord stimulator implantation
[**2191**]-removed in [**2192**]
10. s/p right hernia repair

Social History:
Social history is significant for current tobacco use (1 pack
every other day). There is no history of alcohol abuse. There is
no family history of premature coronary artery disease or sudden
death.

Family History:
Non-contributory.

Physical Exam:
Blood pressure was 94/65 mm Hg while supine, intubated/sedated.
Pulse was 64 beats/min and regular, respiratory rate was 15
breaths/min.
Generally the patient was well developed, well nourished.

There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVP of 7 cm. The carotid waveform was normal. There was no
thyromegaly. The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor, cyanosis,
clubbing or edema. There were no abdominal, femoral or carotid
bruits. Inspection and/or palpation of skin and subcutaneous
tissue showed no stasis dermatitis, ulcers, scars, or xanthomas.


Pulses:
Right: Carotid 2+ Femoral no bruit, hematoma, bleeding at cath
site Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+


Pertinent Results:
ADMIT LABS: ([**2193-4-15**]):

CBC:
WBC-17.6* RBC-3.86* Hgb-12.8* Hct-37.7* MCV-98 MCH-33.1*
MCHC-33.9 RDW-15.0 Plt Ct-420
Neuts-82.9* Lymphs-11.8* Monos-4.1 Eos-1.0 Baso-0.2

COAGS:
PT-12.7 PTT-71.8* INR(PT)-1.1

CHEMISTRIES:
Glucose-113* UreaN-8 Creat-0.7 Na-137 K-3.9 Cl-105 HCO3-26
AnGap-10
Calcium-8.0* Phos-2.8 Mg-2.5

CARDIAC ENZYMES:
[**2193-4-15**] 11:56PM BLOOD CK(CPK)-737* CK-MB-86* MB Indx-11.7*
[**2193-4-16**] 03:14AM BLOOD CK(CPK)-699* CK-MB-70* MB Indx-10.0*

ABG:
[**2193-4-15**] 08:01PM BLOOD Type-ART Temp-37.0 Rates-14/ Tidal V-600
FiO2-60 pO2-213* pCO2-47* pH-7.40 calTCO2-30 Base XS-3
Intubat-INTUBATED

ECG ([**2193-4-15**]):
Sinus rhythm
Consider left atrial abnormality
Consider left ventricular hypertrophy and possible biventricular
hypertrophy
Nonspecific intraventricular conduction delay
ST-T wave abnormalities with probable QT interval prolonged
although is
difficult to measure - cannot exclude in part ischemia or
drug/metabolic/electrolyte effect
Since previous tracing of [**2192-9-18**], inferior myocardial
infarction less evident

CXR ([**2193-4-15**]):
Irregular opacification at the base of the right lung could
represent pneumonia. There is also a linear opacity more
laterally in the right mid lung, likely atelectasis or scar.
Upper lungs are clear. The patient has had median sternotomy and
coronary bypass grafting. The right hilus is enlarged but has a
vascular appearance. There is no evidence elsewhere of central
adenopathy. Heart size is normal, and there is no pleural
effusion. Endotracheal tube is in standard placement.

CARDIAC CATH ([**2193-4-15**]):
1. Coronary angiography of this right dominant system
demonstrated 3 vessel coronary artery disease.  The LMCA had no
angiographically
apparent flow-limiting disease.  The LAD was occluded at the
ostium.
The LCx had an OM with a 40% mid-vessel stenosis.  The RCA was
occluded
proximally and filled distally by left to right collaterals.
2. Graft angiography demonstrated a SVG-Diagonal with a
thrombotic
occlusion in the proximal segment.  The SVG-OM and SVG-PDA had
stump
occlusions.
3. Arterial conduit angiography demonstrated a patent LIMA-LAD.
4. Limited resting hemodynamics revealed normal systemic
arterial
pressure with a BP of 108/60 mmHg.
5. The lesion in the SVG-Diagonal was treated with thrombectomy,

stenting using a 3.5 mm Cypher stent and post dilation with a
4.0 mm
balloon. Final angiogram showed TIMI III flow with no residual
stenosis,
no residual thrombus, no dissection and no embolization. (See
PTCA
comments)

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Thrombotic occlusion of the SVG-Diagonal.
3. Occluded SVG-OM and SVG-PDA.
4. Patent LIMA-LAD.
5. Succesful stenting of the SVG-Diagonal lesion with Cypher
stent.

ECHO ([**2193-4-16**]):
The left atrium is markedly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with hypokinesis
of the septum, and anterior wall. Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (?#) are moderately thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2) and trivial aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Regional left ventricular dysfunction consistent
with coronary disease. Mild aortic stenosis. Mild mitral
regurgitation.


Brief Hospital Course:
1. NSTEMI:
Patient presented with chest pain that was worse than his usual
chest wall pain and was refractory to percocet.  EKG and cardiac
enzymes were consistent with a NSTEMI.  He presented on heparin
and ASA/Plavix; integrillin was added and he was taken to the
cath lab.

Cardiac cath showed the SVG-Diagonal graft with a thrombotic
occlusion in the proximal segment - this was stented using a 3.5
mm Cypher stent and post dilation with a 4.0 mm balloon.  Final
angiogram showed TIMI III flow with no residual stenosis, no
residual thrombus, no dissection and no embolization.  Of note
the patient became very combative prior to the intervention and
asked to terminate the case.  Consent to intubate was obtained
from the daughter and the patient was sedated and intubated.

Post-cath, the patient was monitored in the CCU and remained
intubated overnight.  His pressures were in the 80s systolic and
he was given IVF boluses; he did not require pressors.  He was
extubated the morning after admission without incident
Echo showed an EF of 35% with antero-septal and apical wall
motion abnormalities.

The integrillin was continues for 18 hours.  ASA and Plavix
(initially daily, increased to [**Hospital1 **] on HD#2) were also continued.
 Metoprolol and captopril were written, but note dosed early on,
given his low blood pressures.  He did not present on a statin;
high dose atorvastatin was added.

Given the patient's depressed EF and CAD, outpatient referral
for possible ICD was recommended.

2. Pneumonia:
At the OSH, the patient had a CXR which showed a possible
pneumonia.  On presentaiton, his WBC was elevated and he had low
grade fevers.  The CXR showed a possible RLL infilitrate.  Given
this, he was continued on antibiotics for community acquired
pneumonia (azithromycin and ceftriaxone with plan for seven day
course.  Cultures (sputum and blood) did not show any growth.

3. Hypertension:
Antihypertensives were used, as above.

4. GERD:  Continued PPI.
5. COPD:  Nebs were given PRN.
6. Bipolar disorder:  Monitored; did not required any
medications.
7. Chronic pain:  Morphine, the percocet were used PRN.
8. Constipation:  Bowel regimen


Medications on Admission:
Atenolol 25mg daily
Captopril 12.5mg TID
Percocet PRN
ASA 81mg daily

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*6*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*6*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
7. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 days.
Disp:*2 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Primary:
1. Non ST-elevation myocardial infarction

Secondary:
1. Pneumonia (community acquired)
2. Coronary artery disease
3. Hypertension
4. Gastroesophageal reflux disease
5. Chronic obstructive pulmonary disease
6. Bipolar disorder


Discharge Condition:
Hemodynamically stable.


Discharge Instructions:
You were admitted after having a heart attack.  A stent was
placed in one of the bypass vessels.  In order to help keep this
and the other vessels open you must taken Aspirin and Plavix
EVERY DAY.

If you experience any chest pains, shortness of breath or have
any questions or concerns, please be sure to call your PCP or
your cardiologist.

There have been multiple medications added to your regimen.
These are all important to take given that you had a heart
attack.

ADDED:
1. Plavix:  This helps aspirin to thin the blood and is
especially important given that you had a stent placed.  You
should be sure to take this TWICE A DAY for a minimum of one
year.  Do not skip any doses and do NOT stop this medication
unless instructed by a cardiologist.

2. Aspirin:  This is not a new medication, but you should be
sure to take a full 325mg dose, daily.

3. Atorvastatin:  This is a cholesterol medication that is
important for you to take, given that you had a heart attack.

4. Lisinopril:  This is a blood pressure medication that also
helps in patients who have had heart attacks.

5. Toprol XL:  This is similar to the atenolol you had been on
previously.  It should be taken once daily.

As we have mentioned during your stay, there is nothing you can
do to improve your health more than QUITTING SMOKING.

Followup Instructions:
Please be sure to follow-up with your PCP and your cardiologist.

1. Dr. [**Last Name (STitle) **]:  [**2193-4-26**] at 9:15am.   Please discuss with your
doctor regarding cardiac rehabiliation.
{'Subendocardial infarction, initial episode of care,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Bipolar disorder, unspecified,Tobacco use disorder,Constipation, unspecified,Accidents occurring in residential institution,Other iatrogenic hypotension,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: 72 year old male with known CAD s/p CABG in [**2175**] (see below) and
MI/PCI in [**2187**], chronic chest wall pain, who presented to
[**Hospital 24356**] Hospital with complaints of worsening chest pain
radiating to left arm and back, associated with diaphoresis and
presyncopal symptoms.

MEDICAL HISTORY: 1. Coronary artery disease:
   a. Anterior STEMI / CABG ([**2175**])
   - LIMA to LAD
   - SVG to OM
   - SVG to PDA
   - SVG to D2
   b. Percutaneous coronary intervention ([**2177**])
   - No intervention with one occluded SVG
   c. NQWMI / Percutaneous coronary intervention ([**2187**])
   - LAD total occlusion proximally
   - LCx 90% occluded prox --> s/p stenting (3.0 x 18mm BX
Velocity)
   - RCA total occusion proximally
   - SVG --> PDA patent
   - SVG --> OM total occlusion
   - SVG --> D2 90% distal stenosis --> s/p stenting (4.0 x 18mm
BX velocity)
2. Hypertension
3. Chronic obstructive pulmonary disease
4. Gastroesophageal reflux disease: s/p Billroth II gastrectomy

MEDICATION ON ADMISSION: Atenolol 25mg daily
Captopril 12.5mg TID
Percocet PRN
ASA 81mg daily

ALLERGIES: Ampicillin

PHYSICAL EXAM: Blood pressure was 94/65 mm Hg while supine, intubated/sedated.
Pulse was 64 beats/min and regular, respiratory rate was 15
breaths/min.
Generally the patient was well developed, well nourished.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Social history is significant for current tobacco use (1 pack
every other day). There is no history of alcohol abuse. There is
no family history of premature coronary artery disease or sudden
death. 

### Response:
{'Subendocardial infarction, initial episode of care,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Coronary atherosclerosis of native coronary artery,Esophageal reflux,Bipolar disorder, unspecified,Tobacco use disorder,Constipation, unspecified,Accidents occurring in residential institution,Other iatrogenic hypotension,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
