CHIEF COMPLAINT: 

PRESENT ILLNESS: A 78-year-old gentleman,
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who has been having several
months of substernal chest pain and shortness of breath,
usually relieved with sublingual Nitroglycerin.  Recently,
the pain has increased to weekly and currently almost daily.
The pain is with exertion, but not at rest, and is always
relieved with one sublingual Nitroglycerin.  He has no
complaints of orthopnea, paroxysmal nocturnal dyspnea, or
lightheadedness.

MEDICAL HISTORY: 1) Insulin dependent diabetes
mellitus, 2) Coronary artery disease, status post MI in [**2185**],
3) Hypertension, 4) Hyperlipidemia, 5) Former smoker, 6)
Status post right inguinal herniorrhaphy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known allergies except to shellfish.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Coronary atherosclerosis of native coronary artery,Disruption of external operation (surgical) wound,Other and unspecified angina pectoris,Unspecified pleural effusion,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Crnry athrscl natve vssl,Disrup-external op wound,Angina pectoris NEC/NOS,Pleural effusion NOS,Atrial fibrillation,Abn react-surg proc NEC,Hypertension NOS,Old myocardial infarct,DMII wo cmp nt st uncntr
Admission Date:  [**2199-5-23**]       Discharge Date:  [**2199-6-14**]


Service:  CARDIAC SURGERY

HISTORY OF PRESENT ILLNESS:  A 78-year-old gentleman,
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who has been having several
months of substernal chest pain and shortness of breath,
usually relieved with sublingual Nitroglycerin.  Recently,
the pain has increased to weekly and currently almost daily.
The pain is with exertion, but not at rest, and is always
relieved with one sublingual Nitroglycerin.  He has no
complaints of orthopnea, paroxysmal nocturnal dyspnea, or
lightheadedness.

He underwent a cardiac catheterization on [**2199-5-7**] which
demonstrated severe three-vessel disease, a 70% lesion in the
LAD, a 100% occlusion of the left circumflex, and a 100%
occlusion of the RCA; ejection fraction was 47%.  The patient
was booked for the OR on [**2199-5-23**] for coronary artery
bypass grafting.

PAST MEDICAL HISTORY:  1) Insulin dependent diabetes
mellitus, 2) Coronary artery disease, status post MI in [**2185**],
3) Hypertension, 4) Hyperlipidemia, 5) Former smoker, 6)
Status post right inguinal herniorrhaphy.

MEDS AT ADMISSION:  1) NPH Insulin 24 U in the morning, 14 U
in the evening, 2) regular Insulin 14 U in the morning, 12 U
in the evening, 3) Lopressor 50 mg po bid, 4) Zestril 80 mg
po qd, 5) Benicar 40 mg po qd, 6) Avandia 4 mg po qd, 7)
Zocor 80 mg po q pm, 8) Flomax 0.4 mg po bid, 9) Imdur 30 mg
po qd, 10) hydrochlorothiazide 12.5 mg po qd, 11) Proscar 5
mg po q pm, 12) aspirin 325 mg po qd.

ALLERGIES:  No known allergies except to shellfish.

EXAM AT ADMISSION:  This was a moderately obese gentleman in
no acute distress.  His neck was supple without
lymphadenopathy.  He had no bruits.  His chest was clear.
His heart had a regular rate and rhythm without murmurs.  His
belly was soft, nondistended, nontender.  Extremities were
warm and well-perfused with mild pedal edema.

BRIEF HOSPITAL COURSE:  The patient was brought to the
operating room on [**2199-5-23**] and underwent a four-vessel
CABG with LIMA to LAD, saphenous vein graft to the OM-1, to
the PD and the diagonal.  He did very well in the OR and was
weaned and extubated postoperatively in the CSRU.  His urine
output was adequate, and his blood sugars were elevated, and
an insulin drip was started.  He was otherwise alert and
oriented, moving all of his extremities, with somewhat labile
blood pressure.  He was A-paced with a heart rate of 80 with
an underlying rhythm of 40s in sinus brady.  He continued to
require a Nitroglycerin drip to maintain his blood pressures
adequately low.

By postop day #1, the patient was doing well.  The
Nitroglycerin was weaned off.  He was delined and transferred
to Far-2.  On the floor, he was doing well until
postoperative day #3, when he complained of sudden onset of
chest pain in the lower sternal area.  On examination, he was
found to have a sternal click with some scant serous drainage
from the lower part of the incision.  He was placed on
sternal precautions, and his pain was controlled, and serial
exams were performed throughout the day.  Throughout the
course of the day, he continued to develop worsening wheezing
despite nebulizer treatments.  The decision was ultimately
made to take the patient back to the OR for reclosing of his
sternal dehiscence which was carried out on [**2199-5-27**].

The patient tolerated the procedure well and came out on
low-dose of neo-synephrine.  He remained intubated, and a
chest tube had to be inserted when his postoperative x-ray
demonstrated a large effusion on the left.  His vent was
weaned, and his Nitroglycerin drip was DC'd, and the patient
was extubated on postop day #2 without complication.  He had
been empirically started on Levofloxacin and vancomycin while
we waited for the cultures to come back. All intraoperative
cultures were negative. The patient was
started on his oral cardiac meds.  He was fed a diet.  His
insulin schedule was restarted while the insulin drip was
weaned off.  His sternal wound had a constant infusion of 1%
Betadine.  By postop day #4, the patient was
still having periods where he was requiring a Nitroglycerin
drip, despite being treated with hydralazine, lisinopril,
Lopressor and lasix.  We changed his Lopressor to atenolol PO
which is what he was taking preoperatively, and this seemed
to have a better effect with him.  His chest tubes and Foley
were discontinued on postop day #4.

His subsequent ICU course was notable for marginal
respiratory status.  On postop day #5, the patient was noted
to have an unstable sternum with drainage from the sternal
wound, nonpurulent in nature.  His white count which had been
elevated prior was on its way down, however; and, the patient
had remained afebrile.  The decision was made to observe with
serial exams before deciding if the patient needed to go to
the operating room.  Fortunately, over the next several days,
the patient remained afebrile, his white count continued to
decline, and he was improving.  His cultures ultimately grew
out MRSA from the sputum, but everything else had been
negative. Vancomycin was continued.

On postop day #9, he was doing well.  He was off all drips,
oral Lopressor.  His respiratory status was good, and he was
transferred to the floor where he had a relatively uneventful
course with the exception of a few episodes of atrial
fibrillation for which he was started on amiodarone.  These
episodes of PAF all occurred within the same 48-hour period,
and he has been in sinus ever since achieving adequate levels
of amiodarone.  The incision stopped draining fluid on postop
day #15, although he still had a small click.  White count
and creatinine continued to normalize, and a PICC was placed
for IV vancomycin and Levofloxacin.  Physical therapy had
seen the patient and recommended that he be discharged to
rehab when he was medically cleared.

On postoperative day #16, his respiratory status was somewhat
worsened, and a chest x-ray was obtained which demonstrated a
left effusion that had been increasing in size.  Placement of
a Cook catheter in the left chest was attempted
unsuccessfully, and a 28 French chest tube was placed in
instead which was successful in draining approximately 100 cc
of serosanguineous fluid immediately, followed by
approximately 200 since insertion.  His chest x-ray and his
respiratory status improved, and the chest tube was removed
approximately 48 hours later.  He continued to do well, be
maintained on oral medications, but was still unable to
ambulate very well.  The patient is being discharged to a
rehab facility on [**2199-6-14**] in stable condition.

DISCHARGE DIAGNOSES:  1) Coronary artery disease.  2) New
onset atrial fibrillation.  3) Status post coronary artery
bypass graft x 4.

DISCHARGE EXAMINATION:  Neck was supple without
lymphadenopathy or bruits.  His chest was clear anteriorly
with diminished breath sounds at the bases.  His heart had a
regular rhythm and rate.  His abdomen was soft, nontender,
nondistended.  His incisions were all clean, dry and intact.
He had 1+ pedal edema.  His extremities were warm and
well-perfused.

DISCHARGE MEDICATIONS:  1) tamsulosin 0.4 mg q hs, 2)
finasteride 5 mg po qd, 3) simvastatin 80 mg po q hs, 4)
rosiglitazone 4 mg po qd, 5) percocet 1-2 tabs po q 3-4 h
prn, 6) ipratropium bromide 0.2 mg/ml solution 1 neb
inhalation q 6 h prn wheezing, 7) colace 100 mg po bid, 8)
potassium chloride tablets 20 mEq po bid for 5 days, 9) lasix
40 mg po bid for 5 days, 10) Zantac 150 mg po qd, 11) aspirin
325 mg po qd, 12) guaifenesin codeine cough syrup [**6-1**] ml po
q 6 h as needed, 13) Insulin 24 U NPH, 14 U regular subcu q
am, 14) Insulin 14 U of NPH, 12 U of regular subcutaneous q
pm, 15) heparin 5,000 U subcu [**Hospital1 **], 16) Lopressor 75 mg po
bid, 17) amiodarone 400 mg po tid x 1 week, then 400 mg po
bid x 2 weeks, then 400 mg qd x 2 weeks, then 200 mg
thereafter.
The patient is to see Dr. [**Last Name (STitle) **] in 2 weeks.



                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3113**]

Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36

D:  [**2199-6-14**]  12:33
T:  [**2199-6-14**]  13:30
JOB#:  [**Job Number 93624**]
{'Coronary atherosclerosis of native coronary artery,Disruption of external operation (surgical) wound,Other and unspecified angina pectoris,Unspecified pleural effusion,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 

PRESENT ILLNESS: A 78-year-old gentleman,
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who has been having several
months of substernal chest pain and shortness of breath,
usually relieved with sublingual Nitroglycerin.  Recently,
the pain has increased to weekly and currently almost daily.
The pain is with exertion, but not at rest, and is always
relieved with one sublingual Nitroglycerin.  He has no
complaints of orthopnea, paroxysmal nocturnal dyspnea, or
lightheadedness.

MEDICAL HISTORY: 1) Insulin dependent diabetes
mellitus, 2) Coronary artery disease, status post MI in [**2185**],
3) Hypertension, 4) Hyperlipidemia, 5) Former smoker, 6)
Status post right inguinal herniorrhaphy.

MEDICATION ON ADMISSION: 

ALLERGIES: No known allergies except to shellfish.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Coronary atherosclerosis of native coronary artery,Disruption of external operation (surgical) wound,Other and unspecified angina pectoris,Unspecified pleural effusion,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
