CHIEF COMPLAINT: diaphoresis, bilateral shoulder pain, nausea

PRESENT ILLNESS: This is a 71 year old female with a h/o hypercholestrolemia but
no known coronary disease, 50+ pack year tobacco history who was
at [**Hospital1 18**] for an eye appointment when she experienced bilateral
shoulder discomfort, diaphoresis, and nausea.  Initial EKG
showed evidence of an anterior STEMI (2-3 mm elevations in leads
v1-v4 with ST upsloping in v5 and v6, and reciprocal ST
depression of 2 mm in inferior leads).  Subsequent catherization
was significant for a 100% proximal LAD occlusion, and the
patient recieved a PTCA/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].  The Left Marginal, Left
Circumflex, and the Right Coronary were normal.  Hemodynamics at
time of catherization showed  CO/CI 3.30/1.98 PA 23/15 PCWP 4.
During the procedure, the patient became hypotensive with a SBP
in the 60s.  She was started on pressors, fluids, and a balloon
pump was placed to increase forward flow.  Patient's hypotension
initially improved and she was subsequently transfered to CCU
for close observation and management.  Patient again became
hypotensive and uncomfortable, and tenderness in the RLQ was
noted as [**Doctor Last Name **] as a pulseless/cool right lower extremity.  The
patient post-cath Hematocrit was found to be 19, and she was
immediately transfused 4 U of PRBC and put back on pressors. The
Balloon Pump was pulled and a CT showed evidence of a
retroperitoneal bleed.  Patients hypotension eventually resolved
with medical management, she was taken off of pressors, and her
Hematocrit stabilized.

MEDICAL HISTORY: 1.  Hypercholestrolemia
2.  Osteoporosis
3.  s/p Cholecystectomy
4.  s/p Hysterectomy
5.  Cataracts
6.  Migraines
7.  h/o of positive PPD ([**2082**])

MEDICATION ON ADMISSION: none

ALLERGIES: Alendronic Acid / Lipitor

PHYSICAL EXAM: Post Cath VS:  98.0, 90/48, 95, 17, 100% 4L O2

FAMILY HISTORY: - Mother died of MI at age of 80.
- Father had CABG surgery at age of 89.

SOCIAL HISTORY: - Lives in [**Hospital1 3597**], MA
- 50 + pack year tobacco history.
- Denies current EtOH use.
- Walks [**1-26**] miles a day with no anginal symptoms.
Acute myocardial infarction of other anterior wall, initial episode of care,Hemorrhage complicating a procedure,Congestive heart failure, unspecified,Cardiogenic shock,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pure hypercholesterolemia,Osteoporosis, unspecified
AMI anterior wall, init,Hemorrhage complic proc,CHF NOS,Cardiogenic shock,Crnry athrscl natve vssl,Abn react-cardiac cath,Pure hypercholesterolem,Osteoporosis NOS
Admission Date:  [**2102-9-25**]              Discharge Date:   [**2102-9-29**]

Date of Birth:  [**2031-4-7**]             Sex:   F

Service: MEDICINE

Allergies:
Alendronic Acid / Lipitor

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
diaphoresis, bilateral shoulder pain, nausea

Major Surgical or Invasive Procedure:
catherization with proximal left anterior descending stent
placement

History of Present Illness:
This is a 71 year old female with a h/o hypercholestrolemia but
no known coronary disease, 50+ pack year tobacco history who was
at [**Hospital1 18**] for an eye appointment when she experienced bilateral
shoulder discomfort, diaphoresis, and nausea.  Initial EKG
showed evidence of an anterior STEMI (2-3 mm elevations in leads
v1-v4 with ST upsloping in v5 and v6, and reciprocal ST
depression of 2 mm in inferior leads).  Subsequent catherization
was significant for a 100% proximal LAD occlusion, and the
patient recieved a PTCA/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].  The Left Marginal, Left
Circumflex, and the Right Coronary were normal.  Hemodynamics at
time of catherization showed  CO/CI 3.30/1.98 PA 23/15 PCWP 4.
During the procedure, the patient became hypotensive with a SBP
in the 60s.  She was started on pressors, fluids, and a balloon
pump was placed to increase forward flow.  Patient's hypotension
initially improved and she was subsequently transfered to CCU
for close observation and management.  Patient again became
hypotensive and uncomfortable, and tenderness in the RLQ was
noted as [**Doctor Last Name **] as a pulseless/cool right lower extremity.  The
patient post-cath Hematocrit was found to be 19, and she was
immediately transfused 4 U of PRBC and put back on pressors. The
Balloon Pump was pulled and a CT showed evidence of a
retroperitoneal bleed.  Patients hypotension eventually resolved
with medical management, she was taken off of pressors, and her
Hematocrit stabilized.


Past Medical History:
1.  Hypercholestrolemia
2.  Osteoporosis
3.  s/p Cholecystectomy
4.  s/p Hysterectomy
5.  Cataracts
6.  Migraines
7.  h/o of positive PPD ([**2082**])

Social History:
- Lives in [**Hospital1 3597**], MA
- 50 + pack year tobacco history.
- Denies current EtOH use.
- Walks [**1-26**] miles a day with no anginal symptoms.

Family History:
- Mother died of MI at age of 80.
- Father had CABG surgery at age of 89.

Physical Exam:
Post Cath VS:  98.0, 90/48, 95, 17, 100% 4L O2

GEN - lying flat, uncomfortable, alert and orientedX3
HEENT: PERRL, EOMI, MM dry
NECK: supple, JVP flat
PULM: diffuse wheezing bilaterally, no rhonchi or stidor
CV: RRR, 2/6 SEM at LUSB without radiation, distant heart sounds
ABD: obese, baseline distension, tender in RLQ with no
rebound/guarding/peritoneal signs, NABS
EXTREMITIES: right groin bandage intact with sl ooze. Tender at
groin site but no hematoma appreciated. 1+ DP on left, no pulse
palpated on right.  No bruits.
NEURO: Agitated and uncomfortable. No focal deficits.

Pertinent Results:
[**2102-9-25**] 05:20PM BLOOD WBC-14.2* RBC-3.51* Hgb-11.9* Hct-34.7*
MCV-99* MCH-34.0* MCHC-34.4 RDW-13.3 Plt Ct-387
[**2102-9-25**] 08:35PM BLOOD WBC-10.6 RBC-1.75*# Hgb-6.0*# Hct-18.4*#
MCV-105* MCH-34.1* MCHC-32.5 RDW-13.5 Plt Ct-208
[**2102-9-25**] 10:11PM BLOOD Hct-28.2*#
[**2102-9-26**] 02:30AM BLOOD Hct-40.2#
[**2102-9-26**] 06:31AM BLOOD WBC-19.2*# RBC-4.33# Hgb-14.6# Hct-41.0
MCV-95# MCH-33.8* MCHC-35.7* RDW-15.1 Plt Ct-136*
[**2102-9-27**] 04:08AM BLOOD WBC-17.0* RBC-3.52* Hgb-11.5*# Hct-31.6*
MCV-90 MCH-32.6* MCHC-36.4* RDW-15.4 Plt Ct-103*
[**2102-9-29**] 06:35AM BLOOD WBC-9.5 RBC-3.22* Hgb-10.3* Hct-29.9*
MCV-93 MCH-32.1* MCHC-34.5 RDW-15.2 Plt Ct-147*
[**2102-9-28**] 06:35AM BLOOD Neuts-71.3* Lymphs-23.4 Monos-3.8 Eos-1.3
Baso-0.3
[**2102-9-25**] 05:20PM BLOOD PT-18.9* PTT-150* INR(PT)-1.9
[**2102-9-25**] 05:20PM BLOOD Plt Ct-387
[**2102-9-26**] 06:31AM BLOOD PT-13.5 PTT-28.7 INR(PT)-1.2
[**2102-9-27**] 04:08AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2102-9-29**] 06:35AM BLOOD Plt Ct-147*
[**2102-9-25**] 05:20PM BLOOD Glucose-200* UreaN-15 Creat-0.8 Na-143
K-3.9 Cl-106 HCO3-23 AnGap-18
[**2102-9-26**] 06:31AM BLOOD Glucose-177* UreaN-16 Creat-0.7 Na-142
K-4.7 Cl-113* HCO3-20* AnGap-14
[**2102-9-28**] 06:35AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-145
K-3.5 Cl-108 HCO3-27 AnGap-14
[**2102-9-29**] 06:35AM BLOOD Glucose-92 UreaN-11 Creat-0.6 Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2102-9-25**] 05:20PM BLOOD CK(CPK)-86
[**2102-9-25**] 08:35PM BLOOD CK(CPK)-3319*
[**2102-9-26**] 06:31AM BLOOD CK(CPK)-4315*
[**2102-9-26**] 02:31PM BLOOD CK(CPK)-3043*
[**2102-9-26**] 09:28PM BLOOD CK(CPK)-2226*
[**2102-9-27**] 04:08AM BLOOD ALT-77* AST-229* CK(CPK)-1703*
[**2102-9-25**] 08:35PM BLOOD CK-MB-465* MB Indx-14.0* cTropnT-20.67*
[**2102-9-26**] 06:31AM BLOOD CK-MB-GREATER TH
[**2102-9-26**] 02:31PM BLOOD CK-MB-413* MB Indx-13.6* cTropnT-6.31*
[**2102-9-26**] 09:28PM BLOOD CK-MB-257* MB Indx-11.5* cTropnT-5.06*
[**2102-9-27**] 04:08AM BLOOD CK-MB-154* MB Indx-9.0* cTropnT-4.41*
[**2102-9-25**] 08:35PM BLOOD Calcium-6.7* Mg-1.5*
[**2102-9-29**] 06:35AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.8
[**2102-9-27**] 11:14AM BLOOD %HbA1c-6.0*

CT ADOMEN W/O IV CONTRAST:
There is bibasilar atelectasis. The heart and pericardium are
unremarkable. A right femoral approach Swan-Ganz catheter is
present. The liver, pancreas, adrenals, and kidneys are
unremarkable in appearance. The spleen is somewhat small in
size. The patient is post cholecystectomy with clips seen in the
gallbladder fossa. The intraabdominal large and small bowel are
unremarkable. High density fluid is seen in the parahepatic and
parasplenic spaces. There is a large retroperitoneal hemorrhage
on the right side of the abdomen which extends into the right
pararenal space and into the pelvis. No free air or pathologic
lymphadenopathy is seen within the abdomen. Note is made of
interposition of the large bowel between the liver and anterior
abdominal wall.

CT PELVIS W/O IV CONTRAST:
The retroperitoneal hemorrhage is seen to track into the pelvis.
There is stranding of fat throughout the pelvis. A large right
groin hematoma is present. There is a right femoral approach
catheter. A Foley catheter is seen within a collapsed bladder.
There is marked bladder wall thickening, likely secondary to the
surrounding hemorrhage. The rectum and sigmoid are unremarkable.

The osseous structures are unremarkable.

IMPRESSION:
Large right sided retroperitoneal hemorrhage tracking into the
pelvis. There is also a right groin hematoma. High density fluid
is seen in the parahepatic and parasplenic spaces represents
intraperitoneal hemorrhage. These findings were communicated to
Dr. [**Last Name (STitle) **] at the completion of the study.


PTCA COMMENTS:
  Initial angiography demonstrated a totally occluded proximal
LAD.  We
elected to treat this lesion with PTCA/Stenting.  Heparin and
Integrilin
were administered prophylactically.
  The patient was enrolled in the FLAME trial (Filterwire EZ
distal
protection device for STEMI).  A 7 French XBLAD 3.5 guide
provided
adequate support.  The filterwire would not cross the lesion,
and a PT
[**Name (NI) 9165**] Intermediate wire was passed into the distal LAD.  A 2.5
x 20 mm
Maverick was used to dotter through the lesion, restoring flow.
The
balloon was then inflated at 8 atm, and a 3.0 x 23 mm Cypher DES
was
deployed at 14 atm, jailing the 1st diagonal.  The patient
became
somewhat hypotensive, requiring atropine and pressors, but the
flow in
the LAD and diagonal was normal after administration of
diltiazem.  The
stent was then post-dilated with a 3.5 x 9 mm NC Ranger at 16
atm and 14
atm.  Distal vasodilators were administered through an Ultrafuse
X
catheter.  Given the patient's persistent hypotension, an
intra-aortic
balloon pump was placed through the right femoral arteriotomy
site.
Right heart catheterization demonstrated low filling pressures,
and
fluids with peripheral vasconstrictors were administered.
  Final angiography demonstrated no dissection, no residual
stenosis
within the LAD, with minor ostial narrowing of the jailed D1.
The LAD
and D1 flow was TIMI 2 fast.  The patient left the lab and was
admitted
to the CCU in stable condition.

COMMENTS:
1.  Selective coronary angiography of this right dominant system

revealed one vessel coronary disease.  The LMCA, LCX, and RCA
were
without flow limiting, angiogrpahically apparent coronary artery

disease.  The LAD contained a thromboitc proximal total occusion
just
after the origin.  After the vessel was opened, it could be seen
to give
off two medium caliber diagonal branches and a large septal
branch.  The
first diagonal branch was just after the LAD origin and the
second was
more distal, beyond the septal branch.
2.  Resting hemodynamics revealed low mean PCPW pressure of
4mmHg.
Cardiac index was 2 l/min/m2.
3.  Left ventriculography was not performed.
4.  The patient's central aortic pressure was low throughout the
case
despite agressive IV fluid hydration.  For this reason,
dopamine,
followed by neosynephrine were administered.  When the blood
pressure
remained low, despite these interventions, an inta-aortic baloon
pump
was inserted.  At the end of the case, after several liters of
IV
saline, the patient's blood pressure had stabalized and doses of

pressors were actively being weaned back.   The patient's blood
pressure
at completion of the case had improved to ~90mmHg on 5mcg/kg/min

dopamine and 40mcg/min Neosynephrine.
5. Acute myocardial infarction, managed by successful primary
PCI of the
LAD with a 3.0 x 23 mm Cypher DES, post-dilated with a 3.5 mm
balloon
(see PTCA comments).

FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Low filling pressures.
3. Acute myocardial infarction, managed by successful primary
PCI of the
LAD.

Conclusions:
The left ventricular cavity is mildly dilated. There is severe
regional left
ventricular systolic dysfunction with near akinesis of all
segments. The basal
inferior wall contracts best. No left ventricular thrombus is
identified, but
the apex is mildly aneurysmal. Right ventricular chamber size is
normal. There
is focal dyskinesis of the apical free wall of the right
ventricle. There is a
trivial/physiologic pericardial effusion.


Brief Hospital Course:
Brief Hospital Course by System:

71 year old female with no known coronary disease presented with
Anterior STEMI s/p proximal LAD [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] complicated by
retroperitoneal bleed.

A.  Cardiovascular
Ischemia:  Patient presented with diaphoresis, bilateral
shoulder discomfort, and nausea.  ECG was significant for [**12-27**] ST
elevations in v1-v4 with upsloping in v5-v6, and reciprocal ST
depression of 2mm in inferior leads.  Patient was taken for
catherization where a 100% proximal LAD occlusion was found with
a normal right coronary artery, left marginal, and left
circumflex.  Pt was started on Integrillin and loaded with
Plavix.  A PTCA/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was successfully placed in the LAD.
Patient was transferred to CCU for close monitoring and
observation, due to hypotension during catherization.  Patient's
cardiac enzymes were initally elevated with a peak CPK of 4315,
CPK/MB of 465, MB fraction of 14.0, and Troponin of 20.67.  By
hospital Day #3, Enzymes had trended down to CPK of 1703, CPK/MB
of 154, MB fraction of 9.0, and Troponin of 4.41.  Integrillin
was discontinued once retroperitoneal bleed was identified.
Patient remained on Simvastatin (adverse effects from Lipitor),
Plavix, and ASA.  Once hypotension resolved, patient was put on
and discharged on beta blocker and ACE-Inhibitor.

Pump: At time of catherization, patient was thought to be in
cardiogenic shock secondary to the large anterior MI.  A Balloon
Pump was placed to increase forward flow. However, with a PCWP
of 4, patient was treated for hypovolemia with fluids.
Hemodynamics showed a CO/CI 3.30/1.98 PA 23/15 PCWP 4.  After
catherization, patients hypotension continued and she was
treated with pressors (dopamine + levophed).  A retroperitoneal
bleed was identified and patient had a Hematocrit of 18.4. The
Balloon pump was then pulled and the patient was transfused with
4 [**Location **].  Bedside Echo showed an EF of less than 20% and
severe regional left
ventricular systolic dysfunction with near akinesis of all
segments. No left ventricular thrombus was identified, but the
apex was mildly aneurysmal. Hypotension eventually resolved with
medical management.  When Swanz was pulled on Hospital Day #3,
CO 3.9, CI 2.3, PAP 23/18.  Patient was discharged on beta
blocker and ACE-Inhibitor.

Rhythm:  no issues.

B.  Heme

Patient's hematocrit fell to 18.4 secondary to retroperitoneal
bleed.  Patient was transfused with 4 [**Location **] and bleed
resolved with medical management.  Patients hematocrit at time
of discharge was 31.1.

C. Endo
Patient exhibited evidence of glucose intolerance post-cath with
a Glucose of 480. Patient was managed with sliding scale Insulin
and achieved tight glucose control below 120 during hospital
course.  Patient hemoglobin A1c was 6.0%.

D. Prophx
Patient was given Senna/Colace for constipation prophx.  Due to
retroperitoneal bleed, Heparin was avoided.  However, patient
was on ASA and on venodynes for DVT prophx.

Medications on Admission:
none

Discharge Disposition:
Home

Discharge Diagnosis:
acute MI
CHF
retroperitoneal hemorrhage


Discharge Condition:
good

Discharge Instructions:
please follow up with scheduled appointments and take all
medication as prescribed.

please restrict salt intake to 2gm per day and limit free fluid
intake to less than 1.5 liters per day.  Weigh yourself daily
and report any siginifcant changes to PCP.

call PCP or return to ED if suffering from severe chest pain,
shortness or breath, persistent nausea consitent with angina,
inability to tolerate food or liquid.

Followup Instructions:
Appointment #1:
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 57196**] [**Name (STitle) **].  Phone No. [**Telephone/Fax (1) **]
Date/Time:  [**10-6**] 1:00 p.m.

Appointment #2:
Signal Average EKG.  [**Hospital Ward Name **] BUILDING [**Location (un) 861**] Patient Holding
Area.
DATE/TIME:  [**2102-10-26**] 12:30 PM

Appointment #3:
Provider: [**Name10 (NameIs) 10081**] TESTING Where: BA [**Hospital Unit Name **] ([**Hospital Ward Name **] COMPLEX)
CARDIOLOGY NONINVASIVE Phone:[**Telephone/Fax (1) 3312**] Date/Time:[**2102-10-26**]
1:15 PM

Appointment #4:
Echocardiogram. Where: [**Hospital Ward Name 517**], [**Location (un) **] [**Hospital Unit Name 723**]
[**Apartment Address(1) 57197**]
DATE/TIME: [**2102-10-26**] 10:45 AM.

Appointment #5:
Consult for ICD with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Please call to confirm appointment and get directions at Phone
No: [**Numeric Identifier 54102**]
Where: [**Hospital Ward Name 23**] Building [**Location (un) 436**] Cardiac Services
DATE/TIME: Wednesday [**2102-11-1**] 2 p.m.



Completed by:[**2102-10-3**]
{'Acute myocardial infarction of other anterior wall, initial episode of care,Hemorrhage complicating a procedure,Congestive heart failure, unspecified,Cardiogenic shock,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pure hypercholesterolemia,Osteoporosis, 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: diaphoresis, bilateral shoulder pain, nausea

PRESENT ILLNESS: This is a 71 year old female with a h/o hypercholestrolemia but
no known coronary disease, 50+ pack year tobacco history who was
at [**Hospital1 18**] for an eye appointment when she experienced bilateral
shoulder discomfort, diaphoresis, and nausea.  Initial EKG
showed evidence of an anterior STEMI (2-3 mm elevations in leads
v1-v4 with ST upsloping in v5 and v6, and reciprocal ST
depression of 2 mm in inferior leads).  Subsequent catherization
was significant for a 100% proximal LAD occlusion, and the
patient recieved a PTCA/[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **].  The Left Marginal, Left
Circumflex, and the Right Coronary were normal.  Hemodynamics at
time of catherization showed  CO/CI 3.30/1.98 PA 23/15 PCWP 4.
During the procedure, the patient became hypotensive with a SBP
in the 60s.  She was started on pressors, fluids, and a balloon
pump was placed to increase forward flow.  Patient's hypotension
initially improved and she was subsequently transfered to CCU
for close observation and management.  Patient again became
hypotensive and uncomfortable, and tenderness in the RLQ was
noted as [**Doctor Last Name **] as a pulseless/cool right lower extremity.  The
patient post-cath Hematocrit was found to be 19, and she was
immediately transfused 4 U of PRBC and put back on pressors. The
Balloon Pump was pulled and a CT showed evidence of a
retroperitoneal bleed.  Patients hypotension eventually resolved
with medical management, she was taken off of pressors, and her
Hematocrit stabilized.

MEDICAL HISTORY: 1.  Hypercholestrolemia
2.  Osteoporosis
3.  s/p Cholecystectomy
4.  s/p Hysterectomy
5.  Cataracts
6.  Migraines
7.  h/o of positive PPD ([**2082**])

MEDICATION ON ADMISSION: none

ALLERGIES: Alendronic Acid / Lipitor

PHYSICAL EXAM: Post Cath VS:  98.0, 90/48, 95, 17, 100% 4L O2

FAMILY HISTORY: - Mother died of MI at age of 80.
- Father had CABG surgery at age of 89.

SOCIAL HISTORY: - Lives in [**Hospital1 3597**], MA
- 50 + pack year tobacco history.
- Denies current EtOH use.
- Walks [**1-26**] miles a day with no anginal symptoms. 

### Response:
{'Acute myocardial infarction of other anterior wall, initial episode of care,Hemorrhage complicating a procedure,Congestive heart failure, unspecified,Cardiogenic shock,Coronary atherosclerosis of native coronary artery,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Pure hypercholesterolemia,Osteoporosis, unspecified'}
