CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: 37 yo F w h/o endocarditis after PICC placement veg on AV, AI,
stroke who presented with chest pain. She reports that she was
in her usual state of health recently,without limitation by
symptoms of dyspnea, chest pain. She has occasional
lightheadedness which sounds postural in nature. On the morning
of admit, she awoke with "tightness" in herleft arm and shoulder
which steadily progressed throughout the day. Then around 6 pm
on the day of admission she developed severe, substernal,
spasm-like pain in the anterior chest with radiation to the back
and presented to the ED within 2 hours. This occurred for
several seconds at a time and reports that it would then lessen,
but never fully go away. The pain is worse lying down or sitting
forward and is pleuritic in nature. She reports that the takes
asa and plavix every day and took them today as normal. No
nausea, dyspnea, lightheadedness. No back pain.
.
In the ED, initial vitals were Temp 98.7, HR 90, BP 137/88, RR
18, O2 100%
Labs and imaging significant for negative troponin and CK-MB.
CTA showed no no PE or aortic dissection. Unchanged 19 mm
outpouching from the anterior portion of aortic root is most
likely a pseudoaneurysm based on prior imaging. Multifocal
ground glass and peribronchovascular ground glass opacities
consistent with pneumonia. A bedside echo showed a structure in
the LV.
Patient given CeftriaXONE 1g, dilaudid 1mg with good reduction
in her pain.
Vitals on transfer were 98.4, 84, 123/70, 22, 100%
.
On arrival to the floor, patient continues to have pain, but
greatly diminished. Appears comfortable at this time.
.
REVIEW OF SYSTEMS
On review of systems she denies any history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.

MEDICAL HISTORY: AORTIC VALVE INSUFFIC- Long history:
- [**2142**]: Had PICC line placed for hyperemesis gravidum-->
bacteremia which caused meningitis, septic emboli to kidney's
and aortic valve endocardidits. Managed medically.
.
- [**7-/2144**]: SOB led to dx of aortic insufficiency. Had st Jude
valve replacement.
.
- [**12/2144**]: Again SOB led to echo which showed insuff + cavity
adjacent to aortic valve. The patient was sent to the OR during
that hospitalization for a re-op aortic valve replacement, at
which time a #21 mechanical valve was placed. There was
reconstruction of the anterior mitral leaflets, aortic annulus,
and proximal ascending aorta with a patch. Post op course
complicated by stroke with left sided hemiparesis (resolved
throughout hospitalization), SVT. Blood cultures negative
throughout.
.
- Spring [**2144**]: The patient was readmitted with findings
suggesting a perivalvar abscess and a perivalvar leak along with
partial aortic valve dehiscence. On [**3-/2145**] underwent reoperative
aortic valve replacement with a #23 homograft. The upper portion
of the anterior mitral leaflet attached to the homograft was
sewn into two-thirds of the patient's anterior mitral leaflet.
Samples were sent no organisms and rhemu consult was obtained
that was reportedly negative. Operation complicated by
perioperative MI on [**2145-4-28**] with reintubation necessary.
Emergent cardiac cath revealed high-grade stenosis at the ostium
of the left main artery (?secondary to aortic wall edema) which
required stenting of the left main and placement of intraaortic
balloon pump, which was subsequently weaned. Rpeat cath at [**Hospital1 112**]
in [**10/2145**] showed patent graft.
STROKE with residual left hemiparesis
CONDYLOMA ACUMINATUM
HERNIA - INGUINA
HERNIA - UMBILICAL

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.9 BP=136/82 HR=76 RR=20 O2 sat=97% RA
GENERAL: WDWN female 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: Brother  Diabetes - Type II; Hypertension
Maternal Aunt  [**Name (NI) 3730**]; Diabetes-Adult Onset
Maternal Grandmother  Diabetes-Adult Onset; Mental Disorder
Mother Alive Diabetes - Type II; Hypertension
Grandmother had stroke at 28 years of age

SOCIAL HISTORY: Lives with 2 daughters age 4 and 17. Worked in finacnce for some
Pneumonia, organism unspecified,Aneurysm of heart (wall),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status
Pneumonia, organism NOS,Aneurysm of heart,Hx TIA/stroke w/o resid,Heart valve transplant,Old myocardial infarct,Status-post ptca
Admission Date:  [**2149-8-1**]              Discharge Date:   [**2149-8-1**]

Date of Birth:  [**2112-4-11**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
None

History of Present Illness:
37 yo F w h/o endocarditis after PICC placement veg on AV, AI,
stroke who presented with chest pain. She reports that she was
in her usual state of health recently,without limitation by
symptoms of dyspnea, chest pain. She has occasional
lightheadedness which sounds postural in nature. On the morning
of admit, she awoke with "tightness" in herleft arm and shoulder
which steadily progressed throughout the day. Then around 6 pm
on the day of admission she developed severe, substernal,
spasm-like pain in the anterior chest with radiation to the back
and presented to the ED within 2 hours. This occurred for
several seconds at a time and reports that it would then lessen,
but never fully go away. The pain is worse lying down or sitting
forward and is pleuritic in nature. She reports that the takes
asa and plavix every day and took them today as normal. No
nausea, dyspnea, lightheadedness. No back pain.
.
In the ED, initial vitals were Temp 98.7, HR 90, BP 137/88, RR
18, O2 100%
Labs and imaging significant for negative troponin and CK-MB.
CTA showed no no PE or aortic dissection. Unchanged 19 mm
outpouching from the anterior portion of aortic root is most
likely a pseudoaneurysm based on prior imaging. Multifocal
ground glass and peribronchovascular ground glass opacities
consistent with pneumonia. A bedside echo showed a structure in
the LV.
Patient given CeftriaXONE 1g, dilaudid 1mg with good reduction
in her pain.
Vitals on transfer were 98.4, 84, 123/70, 22, 100%
.
On arrival to the floor, patient continues to have pain, but
greatly diminished. Appears comfortable at this time.
.
REVIEW OF SYSTEMS
On review of systems she denies any history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.


Past Medical History:
AORTIC VALVE INSUFFIC- Long history:
- [**2142**]: Had PICC line placed for hyperemesis gravidum-->
bacteremia which caused meningitis, septic emboli to kidney's
and aortic valve endocardidits. Managed medically.
.
- [**7-/2144**]: SOB led to dx of aortic insufficiency. Had st Jude
valve replacement.
.
- [**12/2144**]: Again SOB led to echo which showed insuff + cavity
adjacent to aortic valve. The patient was sent to the OR during
that hospitalization for a re-op aortic valve replacement, at
which time a #21 mechanical valve was placed. There was
reconstruction of the anterior mitral leaflets, aortic annulus,
and proximal ascending aorta with a patch. Post op course
complicated by stroke with left sided hemiparesis (resolved
throughout hospitalization), SVT. Blood cultures negative
throughout.
.
- Spring [**2144**]: The patient was readmitted with findings
suggesting a perivalvar abscess and a perivalvar leak along with
partial aortic valve dehiscence. On [**3-/2145**] underwent reoperative
aortic valve replacement with a #23 homograft. The upper portion
of the anterior mitral leaflet attached to the homograft was
sewn into two-thirds of the patient's anterior mitral leaflet.
Samples were sent no organisms and rhemu consult was obtained
that was reportedly negative. Operation complicated by
perioperative MI on [**2145-4-28**] with reintubation necessary.
Emergent cardiac cath revealed high-grade stenosis at the ostium
of the left main artery (?secondary to aortic wall edema) which
required stenting of the left main and placement of intraaortic
balloon pump, which was subsequently weaned. Rpeat cath at [**Hospital1 112**]
in [**10/2145**] showed patent graft.
STROKE with residual left hemiparesis
CONDYLOMA ACUMINATUM
HERNIA - INGUINA
HERNIA - UMBILICAL


Social History:
Lives with 2 daughters age 4 and 17. Worked in finacnce for some

time but stroke made it difficult for her to process numbers so
she lost her job. Recently started driving trolly's for MTBA on
the green line. Non smoker, non drinker, no illicit drugs.

Family History:
Brother  Diabetes - Type II; Hypertension
Maternal Aunt  [**Name (NI) 3730**]; Diabetes-Adult Onset
Maternal Grandmother  Diabetes-Adult Onset; Mental Disorder
Mother Alive Diabetes - Type II; Hypertension
Grandmother had stroke at 28 years of age

Physical Exam:
VS: T=97.9 BP=136/82 HR=76 RR=20 O2 sat=97% RA
GENERAL: WDWN female 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 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal 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. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+

Pertinent Results:
Admission Labs:
[**2149-8-1**] 08:53AM BLOOD WBC-10.1# RBC-4.70 Hgb-13.0 Hct-39.5
MCV-84 MCH-27.6 MCHC-32.8 RDW-15.5 Plt Ct-374
[**2149-8-1**] 08:53AM BLOOD Neuts-78.8* Lymphs-14.0* Monos-6.4
Eos-0.5 Baso-0.2
[**2149-7-31**] 10:40PM BLOOD PT-10.4 PTT-31.0 INR(PT)-1.0
[**2149-8-1**] 08:53AM BLOOD Glucose-102* UreaN-12 Creat-0.6 Na-136
K-4.0 Cl-104 HCO3-25 AnGap-11
[**2149-7-31**] 10:40PM BLOOD CK-MB-2
[**2149-7-31**] 10:40PM BLOOD cTropnT-<0.01
[**2149-8-1**] 08:53AM BLOOD CK-MB-2 cTropnT-<0.01
[**2149-8-1**] 08:53AM BLOOD CK(CPK)-107
[**2149-8-1**] 08:53AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.6
.
EKG:  EKG demonstrated sinus rhythm with incomplete RBBB,
nonspecific
ST and T wave changes.  Compared to most recent prior tracing
([**2149-2-4**]) the ST and T wave changes are more pronounced. Compared
with prior from [**2148-10-15**], there is no change.
.
CTA: [**2149-8-1**]
IMPRESSION:
1.  No pulmonary embolism.
2.  Unchanged 1.9 cm outpouching from the anterior portion of
the aortic root, most likely represents a pseudoaneurysm.
3.  Multifocal pneumonia.
.
TTE: [**2149-8-1**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF=55%). Right ventricular chamber size and free wall
motion are normal. An aortic valve homograft is present. There
is a 1.2 x 1.0 cm pseudoaneurysm along the anterior aspect of
the LV outflow tract immediately below the aortic valve. It does
not appear to involve the origin of the right coronary artery
(clip [**Clip Number (Radiology) **]). No high-velocity flow is seen in to/out of the
psuedoaneurysm (suggesting it has not ruptured). No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal with trivial mitral regurgitation. There is
a trivial pericardial effusion.

IMPRESSION: Left ventricular outflow tract pseudoaneurysm as
described above without color flow Doppler evidence of rupture.
Normal functioning aortic valve homograft. Normal biventricular
cavity sizes with preserved global biventricular systolic
function.


Brief Hospital Course:
37 yo woman with complicated history of aortic valve
endocarditis requiring ultimately a homograft with stroke and
perioperative MI requiring left main stent, with evidence of a
possible pseudoaneurysm of the anterior LVOT who presents with
chest pain.

# Chest Pain: The patient has a long cardiac history but no
documented CAD. The current chest pain is not associted with CE
elevation and the EKG is unchanged from a seperate admission for
chest pain in 10/[**2147**]. At that time it was felt that the chest
pain atypical chest pain in the setting of anxiety. At that time
the pseudoaneurysm of the anterior LVOT was noted. The CTA done
in the ED demonstrated no PE or aortic disection. The chest pain
was reduced with dilauded in the ED. Given the negative CTA,
unchanged EKG, negative cardiac enzymes, and echo that showed no
change in the LVOT pseudoaneurysm and the patient had resolution
of her chest pain without reoccurance with activity she was
discharged home.

#PNA: The CTA reported multifocal ground glass and
peribronchovascular ground glass opacities consistent with
pneumonia and she was started on ceftriaxone and azithromycin in
the ED. The patient appears to have stable RUL but there appears
to be new LLL densities compared to CT 10/[**2147**]. The patient
denies cough or fever at this time but does report pleuritic
chest pain. The patient was discharged on oral azithromycin and
Cefpodoxime to complete a 7 day course. Given the multifocal
ground glass and peribronchovascular ground glass opacities a
repeat chest CT as an outpatient may be warranted with
outpatient evaluation by pulmonary if there is not resolution or
progression of the chest CT findings.

Transitional Issues:
You were started on a course of antibiotics and should complete
this course and then follow-up with your primary care doctor.
You may need to have a repeat CT scan of your lungs and a
follow-up appointment with a pulmonologist if the abnormalities
on the CT do not resolve with treatment.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY


Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Azithromycin 500 mg PO Q24H
7 day course
RX *azithromycin 500 mg 1 tablet(s) by mouth Every Day Disp #*7
Tablet Refills:*0
5. Cefpodoxime Proxetil 400 mg PO Q12H
7 day course
RX *cefpodoxime 200 mg 2 tablet(s) by mouth Every day Disp #*14
Tablet Refills:*0
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice each day Disp
#*28 Capsule Refills:*0
6. Acetaminophen 1000 mg PO Q8H Duration: 5 Days


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis: Community Acquired Pneumonia
Seconday Diagnosis: Aortic Insufficiency s/p St Jude's Valve in
past

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


Discharge Instructions:
Ms [**Known lastname **], it was a pleasure taking care of you during your
stay.

You were admitted to the hospital due to chest pain and concern
for cardiac origin of the pain. However, testing showed no
evidence that there was a problem in your heart or with your
heart stent. The CT scan of your lungs did show evidence of a
possible infection at the base of both your left and right
lungs. You were started on a course of antibiotics and should
complete this course and then follow-up with your primary care
doctor. YOu may need to have a repeat CT scan of your lungs and
a follow-up appointment with a pulmonologist if the
abnormalities on the CT do not resolve with treatment.

The following changes were made to your medications:
- Start Cefpodoxime 400mg by mouth twice each day for 7 days
(last day is [**2149-8-8**])
- Start Azithromycin 500mg by mouth once each day for 7 days
(last day is [**2149-8-8**])
- You can take tylenol, 1 gram every 8 hours, for the next 5
days to help manage your pain.
- Continue all your other home medications

Followup Instructions:
Name: CHILDS-[**Last Name (LF) 13686**],[**First Name3 (LF) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Friday [**2149-8-8**] 4:00pm
{'Pneumonia, organism unspecified,Aneurysm of heart (wall),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Old myocardial infarction,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: Chest Pain

PRESENT ILLNESS: 37 yo F w h/o endocarditis after PICC placement veg on AV, AI,
stroke who presented with chest pain. She reports that she was
in her usual state of health recently,without limitation by
symptoms of dyspnea, chest pain. She has occasional
lightheadedness which sounds postural in nature. On the morning
of admit, she awoke with "tightness" in herleft arm and shoulder
which steadily progressed throughout the day. Then around 6 pm
on the day of admission she developed severe, substernal,
spasm-like pain in the anterior chest with radiation to the back
and presented to the ED within 2 hours. This occurred for
several seconds at a time and reports that it would then lessen,
but never fully go away. The pain is worse lying down or sitting
forward and is pleuritic in nature. She reports that the takes
asa and plavix every day and took them today as normal. No
nausea, dyspnea, lightheadedness. No back pain.
.
In the ED, initial vitals were Temp 98.7, HR 90, BP 137/88, RR
18, O2 100%
Labs and imaging significant for negative troponin and CK-MB.
CTA showed no no PE or aortic dissection. Unchanged 19 mm
outpouching from the anterior portion of aortic root is most
likely a pseudoaneurysm based on prior imaging. Multifocal
ground glass and peribronchovascular ground glass opacities
consistent with pneumonia. A bedside echo showed a structure in
the LV.
Patient given CeftriaXONE 1g, dilaudid 1mg with good reduction
in her pain.
Vitals on transfer were 98.4, 84, 123/70, 22, 100%
.
On arrival to the floor, patient continues to have pain, but
greatly diminished. Appears comfortable at this time.
.
REVIEW OF SYSTEMS
On review of systems she denies any history of deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.

MEDICAL HISTORY: AORTIC VALVE INSUFFIC- Long history:
- [**2142**]: Had PICC line placed for hyperemesis gravidum-->
bacteremia which caused meningitis, septic emboli to kidney's
and aortic valve endocardidits. Managed medically.
.
- [**7-/2144**]: SOB led to dx of aortic insufficiency. Had st Jude
valve replacement.
.
- [**12/2144**]: Again SOB led to echo which showed insuff + cavity
adjacent to aortic valve. The patient was sent to the OR during
that hospitalization for a re-op aortic valve replacement, at
which time a #21 mechanical valve was placed. There was
reconstruction of the anterior mitral leaflets, aortic annulus,
and proximal ascending aorta with a patch. Post op course
complicated by stroke with left sided hemiparesis (resolved
throughout hospitalization), SVT. Blood cultures negative
throughout.
.
- Spring [**2144**]: The patient was readmitted with findings
suggesting a perivalvar abscess and a perivalvar leak along with
partial aortic valve dehiscence. On [**3-/2145**] underwent reoperative
aortic valve replacement with a #23 homograft. The upper portion
of the anterior mitral leaflet attached to the homograft was
sewn into two-thirds of the patient's anterior mitral leaflet.
Samples were sent no organisms and rhemu consult was obtained
that was reportedly negative. Operation complicated by
perioperative MI on [**2145-4-28**] with reintubation necessary.
Emergent cardiac cath revealed high-grade stenosis at the ostium
of the left main artery (?secondary to aortic wall edema) which
required stenting of the left main and placement of intraaortic
balloon pump, which was subsequently weaned. Rpeat cath at [**Hospital1 112**]
in [**10/2145**] showed patent graft.
STROKE with residual left hemiparesis
CONDYLOMA ACUMINATUM
HERNIA - INGUINA
HERNIA - UMBILICAL

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T=97.9 BP=136/82 HR=76 RR=20 O2 sat=97% RA
GENERAL: WDWN female 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: Brother  Diabetes - Type II; Hypertension
Maternal Aunt  [**Name (NI) 3730**]; Diabetes-Adult Onset
Maternal Grandmother  Diabetes-Adult Onset; Mental Disorder
Mother Alive Diabetes - Type II; Hypertension
Grandmother had stroke at 28 years of age

SOCIAL HISTORY: Lives with 2 daughters age 4 and 17. Worked in finacnce for some 

### Response:
{'Pneumonia, organism unspecified,Aneurysm of heart (wall),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Heart valve replaced by transplant,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status'}
