CHIEF COMPLAINT: chest pain, hypotension

PRESENT ILLNESS: 73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of
rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on
coumadin), hypertension who has a history of vague chest pain.
She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out.
Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
to a heart rate of 98.  She experienced no chest pain and had no
significant ST-T wave changes.  Nuclear images did show a
posterolateral reversible defect in addition to a small anterior
apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office
for evaluation of near syncope and given an event monitor. Today
she went to the [**Location (un) **] ER due to increasing chest pain over the
past week with associated weakness. No significant findings on
event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of
left shoulder pain radiating down her left arm and up left jaw
for many years and all previous work-up has been negative.
However, in past month, she has developed a new type of chest
discomfort over entire chest and associated with nausea and
feeling fatigued and lightheaded. No palps, no SOB, no LOC, no
association with any activity. She has 4 episodes a day lasting
about 5 minutes. Nothing make it better or worse and they occur
irregardless of activity.
.
Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings
of ischemia. She received SLNTG X3 with no effect. Nitro gtt
started and CP free after 30 min. Then, 45 min later developed
hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500
of NS, then 1L NS bolus. SBP in mid80's and she was transferred
to [**Hospital1 18**].
.
On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP
dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP
rose to 110-130s within 5 minutes. NO chest pain, palps, SOB
during this, but did feel more fatigued.
.
In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling
fatigued, but no other symptoms of CP, palp, SOB, LHD,
dizzyness. At baseline, she can climb 2 flights of stairs and
now feels slightly more fatigued than usual.
.
ROS remarkable for intermittent right eye loss of vision "like
blind pulled down" for past month, occasional tingling and
numbess of right face for at least 6 years (prior to stroke).
+PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP,
recent illnesses, bladder/bowel changes.

MEDICAL HISTORY: - HTN
- hyperlipidemia
- PAF: on coumadin, started propafenone 2 years ago which has
kept her in sinus
- Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no
significant valvular disease
- GERD
- Stroke: 6 years ago with recovery of right hand function
- thyroidectomy due to goiter
- colon cancer s/p surgery and chemotherapy

MEDICATION ON ADMISSION: propafenone 150 mg b.i.d.
aspirin 325 mg
Cozaar 50 mg
Levoxyl 112 mcg daily
Prilosec 20 mg
Zocor 20 mg
metoprolol 50 mg b.i.d.
Coumadin 3 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS 96.0 104/56 62 17 99% 2LNC
Gen: WDWN middle aged 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: There is family history of premature coronary artery disease or
sudden death in brother who died of MI age 51.
Father: stroke, lung ca, HTN, MI

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Other chest pain,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Abnormal coagulation profile,Personal history of malignant neoplasm of large intestine,Esophageal reflux
Chest pain NEC,Atrial fibrillation,Long-term use anticoagul,Hypertension NOS,Hyperlipidemia NEC/NOS,Iatrogenc hypotnsion NEC,Adv eff coronary vasodil,Abnrml coagultion prfile,Hx of colonic malignancy,Esophageal reflux
Admission Date:  [**2151-1-25**]              Discharge Date:   [**2151-1-27**]

Date of Birth:  [**2077-10-24**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain, hypotension

Major Surgical or Invasive Procedure:
Stress MIBI test


History of Present Illness:
73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of
rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on
coumadin), hypertension who has a history of vague chest pain.
She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out.
Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
to a heart rate of 98.  She experienced no chest pain and had no
significant ST-T wave changes.  Nuclear images did show a
posterolateral reversible defect in addition to a small anterior
apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office
for evaluation of near syncope and given an event monitor. Today
she went to the [**Location (un) **] ER due to increasing chest pain over the
past week with associated weakness. No significant findings on
event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of
left shoulder pain radiating down her left arm and up left jaw
for many years and all previous work-up has been negative.
However, in past month, she has developed a new type of chest
discomfort over entire chest and associated with nausea and
feeling fatigued and lightheaded. No palps, no SOB, no LOC, no
association with any activity. She has 4 episodes a day lasting
about 5 minutes. Nothing make it better or worse and they occur
irregardless of activity.
.
Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings
of ischemia. She received SLNTG X3 with no effect. Nitro gtt
started and CP free after 30 min. Then, 45 min later developed
hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500
of NS, then 1L NS bolus. SBP in mid80's and she was transferred
to [**Hospital1 18**].
.
On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP
dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP
rose to 110-130s within 5 minutes. NO chest pain, palps, SOB
during this, but did feel more fatigued.
.
In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling
fatigued, but no other symptoms of CP, palp, SOB, LHD,
dizzyness. At baseline, she can climb 2 flights of stairs and
now feels slightly more fatigued than usual.
.
ROS remarkable for intermittent right eye loss of vision "like
blind pulled down" for past month, occasional tingling and
numbess of right face for at least 6 years (prior to stroke).
+PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP,
recent illnesses, bladder/bowel changes.


Past Medical History:
- HTN
- hyperlipidemia
- PAF: on coumadin, started propafenone 2 years ago which has
kept her in sinus
- Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no
significant valvular disease
- GERD
- Stroke: 6 years ago with recovery of right hand function
- thyroidectomy due to goiter
- colon cancer s/p surgery and chemotherapy


Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.

Family History:
There is family history of premature coronary artery disease or
sudden death in brother who died of MI age 51.
Father: stroke, lung ca, HTN, MI


Physical Exam:
VS 96.0 104/56 62 17 99% 2LNC
Gen: WDWN middle aged 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 8 cm; no carotid bruits
CV: RR, normal S1, S2. I/VI systolic murmur at apex. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace pitting edema; faint DP pulses bilaterally
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.


Pertinent Results:
EKG demonstrated sinus rhythm, 60bpm, nl axis, PR 200 msec, no
ST or TW changes compared to earlier in day. PR from OSH EKG
TELEMETRY demonstrated: normal rhythm,
2D-ECHOCARDIOGRAM: Per patient, she had an echo 1 week prior
which was reportedly normal
ETT: Per Dr. [**Last Name (STitle) 11493**] notes: [**2150-11-9**]. 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol to a heart rate of 98.  She experienced no chest pain
and had no significant ST-T wave changes.  Nuclear images did
show a posterolateral reversible defect in addition to a small
anterior apical defect.

CXR:  In comparison with the study of [**1-25**], the patient has
taken a
better inspiration.  The cardiac silhouette is within normal
limits with mild prominence of the ascending aorta that would
reflect aortic stenosis or hypertension.

Pertinent labs on discharge:
[**2151-1-27**] WBC-3.9* RBC-3.93* Hgb-12.1 Hct-36.0 MCV-92 MCH-30.8
MCHC-33.6 RDW-13.7 Plt Ct-149*
[**2151-1-27**] PT-16.9* PTT-31.5 INR(PT)-1.5*
[**2151-1-26**] PT-32.5* PTT-38.3* INR(PT)-3.4*
[**2151-1-25**] PT-31.8* PTT-37.7* INR(PT)-3.3* ->given 5mg PO vit K
[**2151-1-26**] TSH-2.9 Free T4-1.3
[**2151-1-26**] %HbA1c-6.1*
[**2151-1-26**] Triglyc-107 HDL-40 CHOL/HD-3.3 LDLcalc-70

Brief Hospital Course:
Patient is a 73 y/o F hx PAF on coumadin, HTN, bradycardia and
first degree AVB now presents with chest pressure and
lightheadedness

CAD: Patient has no known diagnosis of CAD, and cardiac cath
from [**2148**] from [**Hospital3 2568**] had clean coronary arteries.  She ruled
out for an MI here and had a stress stress P - MIBI which
revealed no perfusion defects and an LVEF of 65%. Recent stress
test per OSH cardiologist notes echo done last week per Dr.
[**Last Name (STitle) 11493**] no valve abnormalites. Prior report of MS/MR incorrect.
She has been having these symptoms for the past month and her
cardiologist felt that there may be a component of near syncope
[**3-13**] bradycardia as opposed to CAD. However, her symptoms were
relieved with nitro. NO EKG changes. [**Hospital3 **] cath report from
[**2148**] show clean coronary arteries.  Given negative stress,
recent cath that was negative, reportedly normal echo a decision
was made not to cath the patient.  Beta blocker, aspirin, statin
were continued.  Her coumadin was held as an inpatient as she
was supratherapeutic, this drifted down to INR 1.5 upon
discharge, she was discharged with a lovenox bridge.  A1C 6.1%.
LDL 70, HDL 40, Total 131, Trig 107.

Chest Pain: 2 weeks at most 30 min at a time, no assoc w/
exerction, not reproduced w/ palpation dull in nature, several
times per day. Supratherapeutic on couadmin and not pleurtic
making PE less likely, no tenderness on exam so costochondritis
is less likely, cannot rule out coronary vasospasm.  Patient
should also have a workup for GERD as an outpatient.

Rhythm: Hx of paroxsysmal afib,  continue anticoagulation and
propafenone.  INR 1.4 on discharge, discharged with lovenox
bridge with close follow up with her primary cardiologist.

Hypotension: patient was hypotensive in the setting of nitro
gtt, transiently on a dopamine drip for a SBP in the 40s
although the patient was mentating at the time and there is a
question as to whether the pressure was actually as low as
recorded.  Hypotension did not return and the patient was
normotensive with the addition of her home antihypertensive
regimen.

Loss of vision/curtain like loss of vision in R eye on waking
for the past month.  temporal arteritis given ESR of 7 and
normal physical exam.  Normal carotids on exam, possibly TIA,
the patient should have carotid ultrasounds as an outpatient at
an early date if she has not already had them.  She is on
aspirin and anticoagulated.

Medications on Admission:
propafenone 150 mg b.i.d.
aspirin 325 mg
Cozaar 50 mg
Levoxyl 112 mcg daily
Prilosec 20 mg
Zocor 20 mg
metoprolol 50 mg b.i.d.
Coumadin 3 mg daily

Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Propafenone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Continue taking lovenox
injections until INR is between [**3-14**] on coumadin as directed by
your primary care physician.
[**Name Initial (NameIs) **]:*14 syringes* Refills:*1*
10. Outpatient Lab Work
Please check PT/INR on [**2151-1-29**] at Dr.[**Name (NI) 62094**] Office and
every week thereafter. Please follow up results with him to
decide on coumadin dosing and how long to continue with the
lovenox injections


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] Nursing Services

Discharge Diagnosis:
Atypical chest pain

Secondary diagnoses:
Paroxysmal atrial fibrillation on coumadin
Hypertension
Hyperlipidemia
History of rheumatic fever


Discharge Condition:
Good, chest pain free, ambulating


Discharge Instructions:
You were admitted for workup of chest pain, lightheadness. You
had a full workup of your heart which was negative for any
problems with your heart as the reason for your symptoms. This
was including a stress test that was negative for any
significant cardiac abnormalities.

While you were here, your coumadin level (INR) was found to be
low.  We have started you on a medication, Lovenox, to be
injected twice daily. This should be continued until your INR
becomes therapeutic at a level of [**3-14**]. You should follow up with
your primary care doctor this week for regular checks of your
INR to determine when you can stop this medication. Your first
lab check for this will be in 2 days from discharge on [**2151-1-29**]
where you should get your INR checked before your annual
physical exam with Dr. [**Last Name (STitle) 27542**].

Please take all your medications as prescribed and keep all
follow up appointments. We made no changes to your medications
except the addition of the lovenox injections twice a day until
your INR is within the 2-3 range on your coumadin and Dr.
[**Last Name (STitle) 27542**] gives the okay for you to stop the lovenox
injections.

If you develop chest pain, increased shortness of breath, severe
weakness or any other symptom that concerns you, please call
your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room as soon as
possible.

Followup Instructions:
Please keep the following appointment:
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2151-2-15**] 9:40

It is very important that you follow up with your primary care
doctor, Dr. [**Last Name (STitle) 27542**], this week to check your coumadin level
(INR). Please keep your follow up appointment on [**2151-1-29**] with
Dr. [**Last Name (STitle) 27542**]. At this visit, and weekly afterwards, he will
need to follow up on your INR level to decide how long you
should continue on the lovenox injections.
{'Other chest pain,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Abnormal coagulation profile,Personal history of malignant neoplasm of large intestine,Esophageal reflux'}


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, hypotension

PRESENT ILLNESS: 73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of
rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on
coumadin), hypertension who has a history of vague chest pain.
She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out.
Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
to a heart rate of 98.  She experienced no chest pain and had no
significant ST-T wave changes.  Nuclear images did show a
posterolateral reversible defect in addition to a small anterior
apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office
for evaluation of near syncope and given an event monitor. Today
she went to the [**Location (un) **] ER due to increasing chest pain over the
past week with associated weakness. No significant findings on
event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of
left shoulder pain radiating down her left arm and up left jaw
for many years and all previous work-up has been negative.
However, in past month, she has developed a new type of chest
discomfort over entire chest and associated with nausea and
feeling fatigued and lightheaded. No palps, no SOB, no LOC, no
association with any activity. She has 4 episodes a day lasting
about 5 minutes. Nothing make it better or worse and they occur
irregardless of activity.
.
Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings
of ischemia. She received SLNTG X3 with no effect. Nitro gtt
started and CP free after 30 min. Then, 45 min later developed
hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500
of NS, then 1L NS bolus. SBP in mid80's and she was transferred
to [**Hospital1 18**].
.
On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP
dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP
rose to 110-130s within 5 minutes. NO chest pain, palps, SOB
during this, but did feel more fatigued.
.
In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling
fatigued, but no other symptoms of CP, palp, SOB, LHD,
dizzyness. At baseline, she can climb 2 flights of stairs and
now feels slightly more fatigued than usual.
.
ROS remarkable for intermittent right eye loss of vision "like
blind pulled down" for past month, occasional tingling and
numbess of right face for at least 6 years (prior to stroke).
+PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP,
recent illnesses, bladder/bowel changes.

MEDICAL HISTORY: - HTN
- hyperlipidemia
- PAF: on coumadin, started propafenone 2 years ago which has
kept her in sinus
- Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no
significant valvular disease
- GERD
- Stroke: 6 years ago with recovery of right hand function
- thyroidectomy due to goiter
- colon cancer s/p surgery and chemotherapy

MEDICATION ON ADMISSION: propafenone 150 mg b.i.d.
aspirin 325 mg
Cozaar 50 mg
Levoxyl 112 mcg daily
Prilosec 20 mg
Zocor 20 mg
metoprolol 50 mg b.i.d.
Coumadin 3 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS 96.0 104/56 62 17 99% 2LNC
Gen: WDWN middle aged 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: There is family history of premature coronary artery disease or
sudden death in brother who died of MI age 51.
Father: stroke, lung ca, HTN, MI

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. 

### Response:
{'Other chest pain,Atrial fibrillation,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Other iatrogenic hypotension,Coronary vasodilators causing adverse effects in therapeutic use,Abnormal coagulation profile,Personal history of malignant neoplasm of large intestine,Esophageal reflux'}
