CHIEF COMPLAINT: 

PRESENT ILLNESS: Ms. [**Known lastname 44432**] is a 70-year-old
female with a history of diabetes mellitus, hypertension,
hospital the night of [**2183-1-24**] complaining of
generalized fatigue, acute shortness of breath, and recent
increased peripheral edema.  There she was found to be in
congestive heart failure and a blood sugar to be 600.
Electrocardiogram at the outside hospital showed ST
depressions in I and aVL, and ST elevations in V1 and V2.
She was treated with insulin, Heparin drip, but subsequently
beta blocker, Aggrastat, and nitrodrip.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Congestive heart failure, unspecified,Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Acidosis,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
CHF NOS,AMI inferolateral, init,Cardiogenic shock,Acidosis,Acute kidney failure NOS,Crnry athrscl natve vssl,Athscl extrm ntv art NOS,DMII wo cmp nt st uncntr
Admission Date: [**2183-1-27**]       Discharge Date: [**2183-2-24**]

Date of Birth:                  Sex:

Service:
ADDENDUM:  This addendum to the previous discharge summary is
to contain the brief hospital course from [**2-15**] until
the date of discharge.

HOSPITAL COURSE:  1.) Cardiovascular:  Ischemia.  The patient
episodes of chest pain.  There was no evidence that she might
be having active myocardial ischemia.  She was continued on
her aspirin and Lipitor.

In the past, she has been unable to tolerate a beta blocker
and an attempt was not made to start this medication.

congestive heart failure, as evidenced by x-ray and
continuous crackles on examination.  She was intravascularly
depleted but total body volume over loaded. Our approach to
this condition was to initially try to replete intravascular
volume with normal saline but then try to remove some of the
total fluid overload by giving intravenous Bumex.

Our decision to pursue this approach was particularly
afforded by her electrolytes which showed contraction
alkalosis and hyponatremia which was pointing towards severe
intravascular volume depletion.  After about a week, she had
good results with improvement in her intravascular volume
with good urine output, with continuing to be negative on a
daily basis.  Towards the end of this course, we decided to
start the patient on a small dose of ace inhibitor, given the
proven benefit of this medication in congestive heart
failure.

3.) Rhythm.  The patient remained in sinus rhythm throughout.

4.) Hematology. The patient was continued on her Coumadin for
the iliac stent.  Upon discharge, her dose was being
held given that she had a level of 4.8.  Her dose
can be restarted soon after discharge, to maintain a goal of
2.5 to 3.5 INR.

5.) Renal.  The patient is believed to be in acute renal
failure, as a result of aggressive diuresis and contracture
alkalosis. This was corrected by gentle hydration, followed
by diuresis, in which we were able to replete intravascular
volume while removing some of the total body fluid over load.
She had significant improvement in sodium, chloride and
bicarbonate.  Once we had an improvement in her creatinine,
from starting at 2.6 to about 1.9, we decided that she should
be restarted on her Captopril as this medication is
particularly beneficial for her congestive heart failure.
Mild increase in creatinine would be expected and would not
be particularly worrisome.

6.) Musculoskeletal.  The patient has been complaining of a
significant amount of leg pain.  This can be a combination of
significant edema from congestive heart failure, combined
with osteo insufficiency from iliac thrombi and multiple
procedures.  Her pain can be further exacerbated by extensive
pedal immobility secondary to sick, complicated
hospitalization.  Pain is well controlled with Percocet and
Neurontin.  There is no evidence of current vascular
compromise.

DISCHARGE CONDITION:  Stable.

DISPOSITION:  Discharged to a rehabilitation facility.

DISCHARGE DIAGNOSIS:
Coronary artery disease.
Congestive heart failure with ejection fraction of 25%.






                          [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(2) 2139**]

Dictated By:[**Name8 (MD) 5094**]

MEDQUIST36

D:  [**2183-2-23**]  09:26
T:  [**2183-2-24**]  04:35
JOB#:  [**Job Number **]







Name:  [**Known lastname 8720**], [**Known firstname 665**]                     Unit No:  [**Numeric Identifier 8721**]

Admission Date:  [**2183-1-27**]     Discharge Date:  [**2183-2-24**]

Date of Birth:   [**2112-3-24**]     Sex:  F

Service:  CICU

This discharge addendum will include all hospital activity up
to [**2183-2-15**].

ADDENDUM BY SYSTEM:
1. Cardiovascular:  Ischemia.  The patient has had no further
ischemic events.  She was continued on her aspirin and
statin.  Her blood pressure is unable to tolerate an ACE
inhibitor or a beta blocker.

Pump:  Patient became two positive and went back into
congestive heart failure with total body overload.  She
received five days of Natrecor and Lasix which is then
changed to Bumex with a good diuresis occurring on the 4th
and 5th days.

Unfortunately, this was complicated by volume repletion and
acute renal failure with the highest creatinine at this time
being 2.7 with a BUN of 85.  She has no IV access, or
considering IV fluids or at this point we are going to
encourage po intake.

Rhythm:  She is in sinus throughout and stable.

Patient's oxygen saturations were stable at 98% on [**1-23**] liters
of oxygen at the time of this dictation summary.

Peripheral vascular disease:  The patient had a common iliac
stent and she was on Coumadin throughout this admission which
was stable.

Heme:  The patient was guaiac positive and received 1 unit of
packed red blood cells for a hematocrit of about 29 when we
wanted to intervascularly replete her.  She also received 1
unit of fresh-frozen plasma to temporarily correct her INR
for pulling of a left subclavian line.

The patient is likely to go to rehabilitation after her
medical issues are stable.


                              [**First Name8 (NamePattern2) 577**] [**Last Name (NamePattern1) 578**], M.D.

Dictated By:[**Last Name (NamePattern1) 7843**]

MEDQUIST36

D:  [**2183-2-15**]  14:08
T:  [**2183-2-17**]  07:21
JOB#:  [**Job Number 8722**]


Name:  [**Known lastname 8720**], [**Known firstname 665**]                     Unit No:  [**Numeric Identifier 8721**]

Admission Date:  [**2183-1-27**]     Discharge Date: [**2183-2-24**]

Date of Birth:   [**2112-3-24**]     Sex:  F

Service:  CICU

DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure with ejection fraction of 25%.
3. Peripheral vascular disease status post iliac stents.
4. Acute renal failure.

DISCHARGE MEDICATIONS:
1. Neurontin 200 mg po q hs.
2. Lipitor 10 mg po q day.
3. Plavix 75 mg po q day until the end of [**2-25**]. Colace 100 po bid.
5. Aspirin 81 po q day.
6. Glyburide 10 mg po bid.
7. Calcium carbonate 500 mg po tid.
8. Digoxin 0.125 mg po q day.
9. Erythropoietin 10,000 units subQ twice a week.
10. Bumex 5 mg po q day.
11. Captopril 6.25 mg po tid.
12. Senna two tablets po q hs.
13. Multivitamins one cap po q day.
14. Percocet 1-2 tablets po q6h prn.



                   DR.[**Last Name (STitle) **],[**First Name3 (LF) 77**] 12-270


Dictated By:[**Name8 (MD) 2940**]

MEDQUIST36

D:  [**2183-2-23**]  21:29
T:  [**2183-2-24**]  04:38
JOB#:  [**Job Number 8723**]


Admission Date:  [**2183-1-27**]     Discharge Date: [**2183-2-1**]

Date of Birth:   [**2112-3-24**]     Sex:  F

Service:  CICU
The indication for transfer to the Cardiac Intensive Care
Unit was hypotension.

HISTORY OF PRESENT ILLNESS:  Ms. [**Known lastname 44432**] is a 70-year-old
female with a history of diabetes mellitus, hypertension,
hospital the night of [**2183-1-24**] complaining of
generalized fatigue, acute shortness of breath, and recent
increased peripheral edema.  There she was found to be in
congestive heart failure and a blood sugar to be 600.
Electrocardiogram at the outside hospital showed ST
depressions in I and aVL, and ST elevations in V1 and V2.
She was treated with insulin, Heparin drip, but subsequently
beta blocker, Aggrastat, and nitrodrip.

She was then transferred to [**Hospital1 188**] on the [**1-27**] for cardiac catheterization.
Over the last evening prior to the catheterization, the
patient developed significant epistaxis requiring
discontinuation of her 2B3A inhibitor and Heparin.
Subsequently, she became hypotensive in the Cardiac
Catheterization Waiting Room, and developed new ST
elevations.  She was taken to cardiac catheterization, where
she was found to have severe three vessel disease.  The right
coronary artery was stented.  She was also found to have a
cold left foot and found to have thrombus of her left iliac
artery which was thrombectomized.

During the procedure, the patient developed cardiogenic shock and
bradycardic at that point, and intra-aortic balloon pump was
inserted, and she was started on dopamine drip.  Upon arrival
to the CCU, she was found to have a cold, white right foot, and
was taken back to the cardiac catheterization laboratory to
rule out ischemia.  At that point, balloon pump was switched
from her right to her left side, and she was found to have
diffuse disease in her right lower extremity.  She was then
brought back to the CCU for further
blood pressure support, hemodynamic monitoring, and
respiration ventilation.

PHYSICAL EXAMINATION:  Upon arrival in the Cardiac Intensive
Care Unit, the patient has the following vital signs:
Temperature 97.8, blood pressure 111/68, heart rate 107
irregular.  She was on intra-aortic balloon pump, 1:1
dopamine 7.5 mcg/kg/minute.  She was on vent settings of AC
600, 16, and 100% with PEEP of 5.  She was sating 90%.  Her
arterial blood gas was 7.33, 22, and 426.  General:  She is
intubated and sedated and unresponsive. HEENT:  Pupils are
equal, round, and reactive to light.  CARDIOVASCULAR:
Regular, rate, and rhythm, intra-aortic balloon pump sounds.
LUNGS:  Diffuse rhonchi bilaterally, no wheezes or crackles.
ABDOMEN:  Obese, soft, nontender, and nondistended,
decreased bowel sounds.  EXTREMITIES:  Left lower extremity
was cool to touch without Doppler pulses.  There is 1+
pitting edema on the left, and trace on the right.  Both feet
were mottled and cyanotic.

LABORATORY DATA AND STUDIES:  Patient had first cardiac
catheterization:  Three vessel disease, left anterior
descending artery with a 70% proximal lesion, 60% mid vessel
lesion, 80% distal lesion, first diag was 60% lesion, left
circumflex was occluded and filled with collaterals to left
anterior descending artery.  The right coronary artery was
diffusely diseased with a 90% lesion.  There is a large
thrombus in the left common iliac vein, and it was
thrombectomized and a stent placed to the external common
iliac arteries, but the left internal iliac was jailed, and
not stented.  She had diffuse disease in her left superficial
femoral artery and markedly elevated pulmonary capillary
wedge pressure.  Please see catheterization report for full
details.

On catheterization #2, she had the right intra-aortic balloon
pump discontinued and one placed on her left.  She was found
to have a right common femoral artery with mild disease, a
superficial femoral artery on the right with severe disease,
and total occlusion at the adductor canal and anterior
tibialis a anteriors the sole artery to her foot which did
not fill.   On her left side, she had a superficial femoral
artery severe disease that was diffuse.  She also had the
anterior tibial which was the principal vessel to the foot,
but did not fill either.

She had the following laboratory values:  Her white blood
cell count was 15.9, rose to 20 on her return to the CCU.
Her hematocrit is 28.4, platelets of 210.  PT 13.7, PTT 24.4,
INR of 1.2.  Her urinalysis showed large blood, trace
protein, traced ketones, and 6 red blood cells.  Her anion
gap is 29.  CHEM-7:  Sodium 129, potassium 5.3, chloride 94,
bicarb 11, BUN 71, and creatinine 2.2 with a glucose of 478.
Her CKs went from 299 to 290 to 260 to 437.  Her CK MB from 6
to 7 to 6 and to 15, and her troponin was 9.3, 7.1, 22.8.

Of note, her CKs continued to trend up.  Her CKs from 437, to
80, 91, to 1145, and MB from 15 to 28 to 21.  She had a peak
lactate of 3.1, and CK peaked at 229, MB of 42, and troponin
of 33.5.  She had an albumin of 2.2.  She had sputum sample
from the 8th with greater than 25 PMN's, less than 10 epi's,
and 2+ yeast, but all cultures including urine and blood
cultures have been negative.

She had a chest x-ray on the 8th, which showed mild
congestive heart failure.  She had an echocardiogram which
showed a mildly dilated left atrium, severe global left
ventricular hypokinesis, an ejection fraction of roughly 25%,
and 1+ mitral regurgitation.

Of note, over the course of the subsequent two days, the
patient's platelet count went from 117 to 96 to 78 down to
49.  She had an ALT of 54, an AST of 76.

Her electrocardiogram showed sinus rhythm at 120, normal
axis, and left bundle pattern upon arrival.

HOSPITAL COURSE:
1. Cardiovascular:  The patient arrived at the CCU in
cardiogenic shock with an elevated pulmonary capillary wedge
pressure.  She was continued on an intra-aortic balloon pump
for roughly 60 hours, and slowly weaned off her pressors.
The intra-aortic balloon pump was discontinued on [**1-31**], and the patient defended her blood pressure well off
the balloon pump and the pressors were gradually weaned off.

Initially of interest, the patient was started on dopamine to
which she had a correspondence in regards to a low SVR and
she was switched to Neo-Synephrine which had a better
response in maintaining her blood pressure more adequately.
It is noted that she had a non-ST elevation myocardial
infarction, and had a stent to her right coronary artery.
She has three vessel disease, but it did not appear amenable to
further percutaneous or surgical revasculariztaion.

She is to be treated with Plavix, and aspirin, and statin,
and beta blocker, and ACE inhibitor when her blood pressure
is tolerated.

2.  Peripheral vascular disease:  The patient has
extensive peripheral vascular disease in both extremities.  She
had acute thrombosis of the left common iliac artery which
per Vascular is due to a local reaction from the vessel wall
and not embolism of the heart.  The thrombus was interjected
in the cardiac catheterization laboratory with restoration of
flow, however, the patient's lungs remained cool, and only
gradually retained appreciable regain of her pulses over the
next three or four days.

The plan was to have the patient revascularize when she was
hemodynamically stable.  The Vascular Surgery team also
recommended anticoagulating the patient with Heparin and
Coumadin to preserve blood flow to the lower extremities to
prevent further thrombosis.

3. Hematologic:  The patient was treated with Heparin drip
while she was on the intra-aortic balloon pump.  She
subsequently developed drop in her platelets which was
initially thought to be due to Heparin induced
thrombocytopenia, HIT antibodies which were negative, and
after Hematology was consulted, and they suggested it is not
heparin induced thrombocytopenia but rather platelet
destruction from the intra-aortic balloon pump.  However, in
the interim, she was changed over to Argatroban which she
tolerated well for anticoagulation.  When the balloon pump
was discontinued, the patient was restarted on Heparin drip
for her peripheral vascular disease in the attempt and plan
to transition her to Coumadin for anticoagulation for the
peripheral vascular disease.

Per Hematology, they would prefer that the patient not be
labeled as having Heparin induced thrombocytopenia as this is
likely not the case of their assessment.



                          [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7169**]

Dictated By:[**Last Name (NamePattern1) 11801**]

MEDQUIST36

D:  [**2183-2-1**]  12:55
T:  [**2183-2-4**]  05:39
JOB#:  [**Job Number 46514**]
{'Congestive heart failure, unspecified,Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Acidosis,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities, unspecified,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: Ms. [**Known lastname 44432**] is a 70-year-old
female with a history of diabetes mellitus, hypertension,
hospital the night of [**2183-1-24**] complaining of
generalized fatigue, acute shortness of breath, and recent
increased peripheral edema.  There she was found to be in
congestive heart failure and a blood sugar to be 600.
Electrocardiogram at the outside hospital showed ST
depressions in I and aVL, and ST elevations in V1 and V2.
She was treated with insulin, Heparin drip, but subsequently
beta blocker, Aggrastat, and nitrodrip.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Congestive heart failure, unspecified,Acute myocardial infarction of inferolateral wall, initial episode of care,Cardiogenic shock,Acidosis,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Atherosclerosis of native arteries of the extremities, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
