CHIEF COMPLAINT: Near syncope.

PRESENT ILLNESS: This is a 66-year-old female
with multiple medical problems who was brought to the
Emergency Room after complaining of fatigue and slumping over
in the chair, although reportedly not losing consciousness
per her family.

MEDICAL HISTORY: 1.  Coronary artery disease status
post coronary artery bypass grafting in [**2132**] with LIMA to
left anterior descending and saphenous vein graft to
posterior descending artery.  She is also status post
catheterization with a stent to the left circumflex in [**2135**],
and is status post catheterization in [**2140**] showing patent
grafts.  Most recent cardiac catheterization in [**2143-3-28**]
showed elevated right and left-sided filling pressures with
prominent V-wave and pulmonary capillary wedge pressure
tracing, preserved cardiac output, left main coronary artery
with a 95% hazy lesion extending into the proximal left
circumflex.  It also showed secondary pulmonary hypertension,
hemiballismus.  2.  History of ventricular tachycardia for
which Amiodarone was started.  3.  Left ventricular thrombus.
4.  Congestive heart failure with an ejection fraction of
25-30% which was recently decreased to 15%.  Question of
apical akinesis as well.  5.  Hypertension.  6.
Hyperlipidemia.  7.  Severe mitral regurgitation.  8.
End-stage renal disease on hemodialysis times two months.
She is dialyzed Tuesday, Thursday and Saturday.  9.  History
of cerebrovascular accident with questionable residual right
upper extremity weakness in the presence of hemiballismus in
the acute setting.  Reportedly the cerebrovascular accident
is a 3 cm left parietal infarction.  10.  Chronic obstructive
pulmonary disease.  11.  Diabetes mellitus, dependent on
Insulin.  12.  Meniere's disease.  13.  Osteoarthritis.

MEDICATION ON ADMISSION: Amiodarone 400 gravida p.o. q.d.,
Warfarin 5 mg p.o. q.h.s., .................. 75 mg p.o.
t.i.d., Lipitor 40 mg p.o. q.h.s., Plavix 75 mg p.o. q.d.,
Losartan 50 mg p.o. q.d., Atenolol 25 mg p.o. q.d.,
Isosorbide Dinitrate 30 mg p.o. t.i.d., Elavil 10 mg p.o.
q.h.s., Albuterol inhaler p.r.n., Meclizine 25 mg p.o.
t.i.d., Gabapentin 100 mg p.o. q.h.s., Combivent inhaler
p.r.n., Remegel 800 mg p.o. q.d., Nephrocaps 1 tab p.o. q.d.,
Colace 100 mg p.o. b.i.d., Glargine 20 U q.a.m., 10 U q.h.s.,
regular Insulin sliding scale.

ALLERGIES: ASPIRIN, CAPTOPRIL; THE PATIENT CANNOT REMEMBER
HER REACTIONS TO THESE MEDICATIONS.  MORPHINE SULFATE
REPORTEDLY CAUSES ANAPHYLAXIS.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She has a 60 pack-year of tobacco; the
patient has quit.
Other specified cardiac dysrhythmias,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Unspecified septicemia,Congestive heart failure, unspecified,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Aortocoronary bypass status
Cardiac dysrhythmias NEC,Hyp kid NOS w cr kid V,Hyperpotassemia,Septicemia NOS,CHF NOS,Mitral valve disorder,Chr airway obstruct NEC,Aortocoronary bypass
Admission Date:  [**2143-5-7**]       Discharge Date:  [**2143-5-13**]

Date of Birth:   [**2077-3-6**]       Sex:  F

Service:  CCU

CHIEF COMPLAINT:  Near syncope.

HISTORY OF PRESENT ILLNESS:  This is a 66-year-old female
with multiple medical problems who was brought to the
Emergency Room after complaining of fatigue and slumping over
in the chair, although reportedly not losing consciousness
per her family.

She was last dialyzed on Saturday, and upon reaching the
Emergency Room, the patient was found to be in wide complex
bradycardia without discernable P-waves, question of complete
heart block with an increased potassium.  She was treated
with Glucagon Insulin, D50, Bicarbonate, Atropine, and
Calcium Gluconate.

At the time of initial presentation, her heart rate was in
the 30s with a blood pressure of 70/30.  After treatment, she
returned to narrow complex atrial rhythm at a rate of 50.
Her blood pressure remained low.  Chest x-ray showed
congestive heart failure.  Dopamine was started.

PAST MEDICAL HISTORY:  1.  Coronary artery disease status
post coronary artery bypass grafting in [**2132**] with LIMA to
left anterior descending and saphenous vein graft to
posterior descending artery.  She is also status post
catheterization with a stent to the left circumflex in [**2135**],
and is status post catheterization in [**2140**] showing patent
grafts.  Most recent cardiac catheterization in [**2143-3-28**]
showed elevated right and left-sided filling pressures with
prominent V-wave and pulmonary capillary wedge pressure
tracing, preserved cardiac output, left main coronary artery
with a 95% hazy lesion extending into the proximal left
circumflex.  It also showed secondary pulmonary hypertension,
hemiballismus.  2.  History of ventricular tachycardia for
which Amiodarone was started.  3.  Left ventricular thrombus.
4.  Congestive heart failure with an ejection fraction of
25-30% which was recently decreased to 15%.  Question of
apical akinesis as well.  5.  Hypertension.  6.
Hyperlipidemia.  7.  Severe mitral regurgitation.  8.
End-stage renal disease on hemodialysis times two months.
She is dialyzed Tuesday, Thursday and Saturday.  9.  History
of cerebrovascular accident with questionable residual right
upper extremity weakness in the presence of hemiballismus in
the acute setting.  Reportedly the cerebrovascular accident
is a 3 cm left parietal infarction.  10.  Chronic obstructive
pulmonary disease.  11.  Diabetes mellitus, dependent on
Insulin.  12.  Meniere's disease.  13.  Osteoarthritis.

MEDICATIONS ON ADMISSION:  Amiodarone 400 gravida p.o. q.d.,
Warfarin 5 mg p.o. q.h.s., .................. 75 mg p.o.
t.i.d., Lipitor 40 mg p.o. q.h.s., Plavix 75 mg p.o. q.d.,
Losartan 50 mg p.o. q.d., Atenolol 25 mg p.o. q.d.,
Isosorbide Dinitrate 30 mg p.o. t.i.d., Elavil 10 mg p.o.
q.h.s., Albuterol inhaler p.r.n., Meclizine 25 mg p.o.
t.i.d., Gabapentin 100 mg p.o. q.h.s., Combivent inhaler
p.r.n., Remegel 800 mg p.o. q.d., Nephrocaps 1 tab p.o. q.d.,
Colace 100 mg p.o. b.i.d., Glargine 20 U q.a.m., 10 U q.h.s.,
regular Insulin sliding scale.

ALLERGIES:  ASPIRIN, CAPTOPRIL; THE PATIENT CANNOT REMEMBER
HER REACTIONS TO THESE MEDICATIONS.  MORPHINE SULFATE
REPORTEDLY CAUSES ANAPHYLAXIS.

SOCIAL HISTORY:  She has a 60 pack-year of tobacco; the
patient has quit.

PHYSICAL EXAMINATION:  Vital signs:  On admission temperature
was 97.1??????, blood pressure 93/48, respirations 17, pulse 64,
oxygen saturation 97% on 2 L nasal cannula.  General:  The
patient was somnolent but arousable, barely coherent.
Cardiovascular:  Regular, rate and rhythm.  Barely audible
heart sounds.  No peripheral edema.  Positive jugular venous
distention.  Pulmonary:  Lungs coarse with diffuse rales.
Abdomen:  Soft, nontender, nondistended.  Neurological:  No
focal or neurological deficits.  Somnolent but arousable.

LABORATORY DATA:  White blood cell count 10.1, hematocrit
33.8, platelet count 258; INR 2.8; potassium 5.0, this
potassium was obtained after treatment for a hemolyzed
potassium of 7.9, creatinine 10.1, BUN 66, glucose 194,
magnesium 2.7, calcium 9.2, sodium 135, CK 42, MB not
applicable.

Electrocardiogram showed non-sinus atrial rhythm.

Chest x-ray showed congestive heart failure with bilateral
effusions.

HOSPITAL COURSE:  1.  Arrhythmia:  His bradycardia and
hypertension was attributed to a combination of Amiodarone
and beta-blocker used in the setting of end-stage renal
disease with hyperkalemia.  Withholding of Amiodarone and
beta-blocker together with treatment of hyperkalemia and
dialysis allowed the patient to return to normal sinus
rhythm.
Dopamine was initially required to maintain a heart rate
greater than 50 and to maintain an adequate blood pressure.
It should be noted that the patient has had in the recent
past a subclavian to subclavian graft constructed in her left
upper pectoral/anterior deltoid region.  This anatomy results
in a falsely low blood pressure in the left arm, both by
manual cuff and by arterial line.  Manual blood pressure
taken on the right arm is consistently about 20 points
systolic higher than a blood pressure taken on the left and
correlates better with clinical status.  It is recommended
that in the future, the right arm be used for blood pressure
readings.

After return of heart rhythm to normal sinus at a normal
rate, the patient still required Dopamine for blood pressure
support.  It is unclear how much of this blood pressure
support was necessary given that the story behind the blood
pressure discrepancy had not yet been discovered, and the
patient was likely in early sepsis, as described below.

After a couple of days of antibiotics and monitoring of her
blood pressure in the right arm, the patient was able to be
weaned off Dopamine without problem.  Amiodarone and
beta-blocker were held throughout the hospitalization, and
she remained in sinus rhythm at a normal rate for the rest of
the duration of the hospitalization.

2.  Fluid status:  The patient is essentially aneuric.  She
became hypoxic on the morning after admission secondary to
pulmonary edema failure.  She was briefly intubated, both for
airway protection and to provide adequate oxygenation until
she can be dialyzed.  After dialysis, she was weaned to
pressure support and extubated.  She was continued on
hemodialysis while in-house every other day with removal of
2.0-2.5 L of fluid by ultrafiltrate at each dialysis session.

She was followed by Nephrology while in-house and was
continued on Nephrocaps while her Remegel was increased to
t.i.d. with meals, and she was also started on PhosLo.  She
was also eventually placed on a 2 g sodium diet with a 1500
cc/day fluid restriction.  She did have one other episode
prior to her dialysis on [**2143-5-11**], where she became very
dyspneic just prior to her dialysis.  Dialysis with removal
of fluid allowed for complete resolution of these symptoms.

3.  Sepsis:  After the patient was able to maintain herself
in sinus rhythm at a normal rate, she required Dopamine for
blood pressure support as indicated above.  During this time,
she spiked a temperature to 104?????? and developed a leukocytosis
to 18.  She was empirically started on Vancomycin and
Levaquin, both dosed renally.

After about five days, her Vancomycin was discontinued, and
she was continued on Levaquin.  There was marked clinical
improvement after 48 hours on antibiotics.  A respiratory
source was suspected, as blood cultures remained negative,
urine cultures remained negative, and one respiratory culture
showed rare growth of ..................  She will be
continued on renally dosed Levaquin through [**2143-5-18**], to
complete a 10-day course.

4.  Anticoagulation:  The patient is maintained on Coumadin
as an outpatient for her left ventricular thrombus.  When
started on Levaquin, her INR became supratherapeutic.  Her
Coumadin was intermittently held to allow return of her INR
to a therapeutic range.

On the day of discharge after holding her Coumadin for two
out of the three previous nights, her INR was still 4.1.  She
is following up in two days with her primary care physician.
[**Name10 (NameIs) **] Coumadin will be held at discharge, and she will receive
5 mg p.o. Vitamin K prior to leaving the hospital.

5.  Hyperkalemia:  A Nutrition consult was called to discuss
a proper renal diet with the patient.  She was advised to
stay away from foods that were high in potassium, given the
implication of hyperkalemia and the etiology of her symptoms
causing this hospitalization.

6.  Coronary artery disease:  Given that the patient is
allergic to Aspirin, she was started on ...................
Her Lipitor and Plavix were continued.  Given that her blood
pressure remained on the low side of normal throughout her
hospitalization with a normal sterile fashion and rate, her
Atenolol, Isosorbide Dinitrate and Losartan were not
restarted.

7.  Diabetes:  Glucose control was initially difficult, and
while on the ventilator, the patient was maintained on an
Insulin drip.  This was converted to a sliding scale and
eventually converted back to her home dose of Glargine 20 in
the morning and 10 at night with a sliding scale.  Adequate
glucose control was achieved.

DISCHARGE STATUS:  The patient is stable for discharge home
with visiting nurse and home physical therapy.

FOLLOW-UP:  She will follow-up with her primary care
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4251**] on Wednesday, [**2143-5-15**], at noon.
This appointment has been scheduled.  She will also follow-up
with her cardiologist, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2143-6-12**],
at 11:30; this appointment has also been scheduled.  She was
last dialyzed on the day of discharge, [**2143-5-13**], and is
to resume her hemodialysis on Tuesday, [**2143-5-14**], as an
outpatient.

DISCHARGE INSTRUCTIONS:  She is to be discharged on a 2 g/day
sodium-limited diet, as well as a 1500 cc/day fluid
restriction.  She was also advised about avoiding high
potassium foods.  She was advised not to restart her Elavil,
Gabapentin, Meclizine, ................., Isosorbide
Dinitrate, Atenolol or Losartan until authorized to do so by
Dr. [**Last Name (STitle) **] and/or Dr. [**Last Name (STitle) 4251**].

The patient was also advised not to restart her Amiodarone.
She will not resume taking her Coumadin until authorized to
do so by her primary care physician.  [**Name10 (NameIs) **] is because her INR
was 4.1 on the day of discharge.

DISCHARGE MEDICATIONS:  Lipitor 40 mg p.o. q.d., Plavix 75 mg
p.o. q.d., .................. 200 mg p.o. b.i.d., Remegel 800
mg p.o. t.i.d. with meals, PhosLo 2 tab p.o. t.i.d. with
meals, Nephrocaps 1 cap p.o. q.d., Colace 100 mg p.o. q.d.,
Albuterol inhalers p.r.n., Combivent inhalers p.r.n.,
Protonix 40 mg p.o. q.d., Levofloxacin 250 mg p.o. q.o.d., to
be started the evening of [**2143-5-14**], last dose to be
taken [**2143-5-18**].

DISCHARGE DIAGNOSIS:
1.  Symptomatic bradycardia and hypotension secondary to
Amiodarone and beta-blocker use in the setting of end-stage
renal disease and hyperkalemia.
2.  Sepsis of unknown etiology.
3.  End-stage renal disease on hemodialysis.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.  [**MD Number(1) 1009**]

Dictated By:[**Last Name (NamePattern1) 99067**]
MEDQUIST36

D:  [**2143-5-13**]  13:51
T:  [**2143-5-13**]  15:02
JOB#:  [**Job Number 99068**]
{'Other specified cardiac dysrhythmias,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Unspecified septicemia,Congestive heart failure, unspecified,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Aortocoronary bypass 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: Near syncope.

PRESENT ILLNESS: This is a 66-year-old female
with multiple medical problems who was brought to the
Emergency Room after complaining of fatigue and slumping over
in the chair, although reportedly not losing consciousness
per her family.

MEDICAL HISTORY: 1.  Coronary artery disease status
post coronary artery bypass grafting in [**2132**] with LIMA to
left anterior descending and saphenous vein graft to
posterior descending artery.  She is also status post
catheterization with a stent to the left circumflex in [**2135**],
and is status post catheterization in [**2140**] showing patent
grafts.  Most recent cardiac catheterization in [**2143-3-28**]
showed elevated right and left-sided filling pressures with
prominent V-wave and pulmonary capillary wedge pressure
tracing, preserved cardiac output, left main coronary artery
with a 95% hazy lesion extending into the proximal left
circumflex.  It also showed secondary pulmonary hypertension,
hemiballismus.  2.  History of ventricular tachycardia for
which Amiodarone was started.  3.  Left ventricular thrombus.
4.  Congestive heart failure with an ejection fraction of
25-30% which was recently decreased to 15%.  Question of
apical akinesis as well.  5.  Hypertension.  6.
Hyperlipidemia.  7.  Severe mitral regurgitation.  8.
End-stage renal disease on hemodialysis times two months.
She is dialyzed Tuesday, Thursday and Saturday.  9.  History
of cerebrovascular accident with questionable residual right
upper extremity weakness in the presence of hemiballismus in
the acute setting.  Reportedly the cerebrovascular accident
is a 3 cm left parietal infarction.  10.  Chronic obstructive
pulmonary disease.  11.  Diabetes mellitus, dependent on
Insulin.  12.  Meniere's disease.  13.  Osteoarthritis.

MEDICATION ON ADMISSION: Amiodarone 400 gravida p.o. q.d.,
Warfarin 5 mg p.o. q.h.s., .................. 75 mg p.o.
t.i.d., Lipitor 40 mg p.o. q.h.s., Plavix 75 mg p.o. q.d.,
Losartan 50 mg p.o. q.d., Atenolol 25 mg p.o. q.d.,
Isosorbide Dinitrate 30 mg p.o. t.i.d., Elavil 10 mg p.o.
q.h.s., Albuterol inhaler p.r.n., Meclizine 25 mg p.o.
t.i.d., Gabapentin 100 mg p.o. q.h.s., Combivent inhaler
p.r.n., Remegel 800 mg p.o. q.d., Nephrocaps 1 tab p.o. q.d.,
Colace 100 mg p.o. b.i.d., Glargine 20 U q.a.m., 10 U q.h.s.,
regular Insulin sliding scale.

ALLERGIES: ASPIRIN, CAPTOPRIL; THE PATIENT CANNOT REMEMBER
HER REACTIONS TO THESE MEDICATIONS.  MORPHINE SULFATE
REPORTEDLY CAUSES ANAPHYLAXIS.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: She has a 60 pack-year of tobacco; the
patient has quit. 

### Response:
{'Other specified cardiac dysrhythmias,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hyperpotassemia,Unspecified septicemia,Congestive heart failure, unspecified,Mitral valve disorders,Chronic airway obstruction, not elsewhere classified,Aortocoronary bypass status'}
