CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 71 year old female
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], who has previously had two stents
to the right coronary artery, who was admitted to [**Hospital1 346**] initially for an outpatient cardiac
catheterization as a result of a recent positive exercise
tolerance test.

MEDICAL HISTORY: 1.  Cardiomyopathy.
2.  Congestive heart failure.
3.  Previous right coronary artery interventions, one in
[**2155**], and one in [**2156**], recent positive exercise tolerance
test on [**2158-3-24**].
4.  Hypertension.
5.  Hypercholesterolemia.
6.  Noninsulin dependent diabetes mellitus.
7.  Anxiety disorder.
8.  Obesity.
9.  Status post appendectomy.
10. Status post cholecystectomy.
11. Status post bilateral oophorectomy.

MEDICATION ON ADMISSION: 1.  Aspirin 325 mg q.d.
2.  Potassium Chloride 20 meq q.d.
3.  Bumex 1 mg q.d.
4.  Norvasc 5 mg q.d.
5.  Hydralazine 50 mg q.i.d.
6.  Imdur 30 mg q.d.
7.  Atenolol 50 mg q.d.
8.  Digoxin 0.125 mg q.d.
9.  Ativan 0.5 mg p.r.n.
10. DiaBeta 5 mg p.o. q.d.
11. Zaroxolyn 5 mg p.r.n.
12. Multivitamin one q.d.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Cardiogenic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Acute respiratory failure
Crnry athrscl natve vssl,CHF NOS,Surg compl-heart,Cardiogenic shock,Accidental op laceration,Acute kidney failure NOS,Acute respiratry failure
Admission Date:  [**2158-4-12**]       Discharge Date:  [**2158-5-18**]

Date of Birth:   [**2086-6-12**]       Sex:  F

Service:  CARDIOTHORACIC SURGERY

HISTORY OF PRESENT ILLNESS:  This is a 71 year old female
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], who has previously had two stents
to the right coronary artery, who was admitted to [**Hospital1 346**] initially for an outpatient cardiac
catheterization as a result of a recent positive exercise
tolerance test.

PAST MEDICAL HISTORY:
1.  Cardiomyopathy.
2.  Congestive heart failure.
3.  Previous right coronary artery interventions, one in
[**2155**], and one in [**2156**], recent positive exercise tolerance
test on [**2158-3-24**].
4.  Hypertension.
5.  Hypercholesterolemia.
6.  Noninsulin dependent diabetes mellitus.
7.  Anxiety disorder.
8.  Obesity.
9.  Status post appendectomy.
10. Status post cholecystectomy.
11. Status post bilateral oophorectomy.

MEDICATIONS ON ADMISSION:
1.  Aspirin 325 mg q.d.
2.  Potassium Chloride 20 meq q.d.
3.  Bumex 1 mg q.d.
4.  Norvasc 5 mg q.d.
5.  Hydralazine 50 mg q.i.d.
6.  Imdur 30 mg q.d.
7.  Atenolol 50 mg q.d.
8.  Digoxin 0.125 mg q.d.
9.  Ativan 0.5 mg p.r.n.
10. DiaBeta 5 mg p.o. q.d.
11. Zaroxolyn 5 mg p.r.n.
12. Multivitamin one q.d.

LABORATORY DATA:  On admission were essentially unremarkable.

HOSPITAL COURSE:  The patient was taken to the Cardiac
Catheterization Laboratory on [**2158-4-12**].  Catheterization
revealed two vessel coronary artery disease, significantly
decreased left ventricular function and pulmonary
hypertension.

On [**2158-4-13**], the patient underwent a diagnostic angiogram
secondary to 100 millimeter gradient and systolic blood
pressure from the right to the left arm and she was found to
have a totally occluded left subclavian artery.  Attempt to
open the artery with angioplasty was unsuccessful.  They were
not able to pass the wire across the lesion.

On [**2158-4-14**], the patient was taken to the operating room with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she underwent coronary artery bypass
graft times two with saphenous vein to the left anterior
descending and saphenous vein to the diagonal.

Postoperatively, she was transported to the cardiac surgery
recovery room from the operating room in stable condition on
intravenous Milrinone, Nipride and insulin drip.  She was
atrially paced.  On postoperative day one, the patient was
weaned from mechanical ventilator and was extubated, however,
over the course of the next two days, the patient was noted
to have decreasing urine output, decreasing cardiac output
and requirement for inotropic support.

On [**2158-4-17**], postoperative day three, an echocardiogram was
obtained which revealed a left ventricular ejection fraction
of 20%, decreased right ventricular function, 2+ mitral
regurgitation and mild pulmonary hypertension.  The following
day the patient was taken to the Cardiac Catheterization
Laboratory to evaluate coronary artery disease and patency of
saphenous vein grafts due to her continued need for inotropic
support.

Catheterization revealed low cardiac output, revealed a 90%
occlusion of her saphenous vein to the diagonal coronary
artery graft as well as 80% left anterior descending lesion.
There was an attempt made to stent the saphenous vein to the
diagonal graft, however, this resulted in dehiscence of the
anastomosis as well as a free perforation into the left
ventricle and pericardium.  An intra-aortic balloon pump was
placed at that time due to hemodynamic instability.

The patient was transported emergently to the operating room
with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where she underwent repair of the
anastomosis.  Postoperatively, the patient was transported
from the operating room to the Cardiac Surgery recovery room
with intravenous Milrinone and Dobutamine as well as an
intra-aortic balloon pump for support.  The patient was kept
sedated and mechanically ventilated over the next two to
three days where she stabilized hemodynamically.

On [**2158-4-21**], the intra-aortic balloon pump was weaned and
discontinued as were her inotropics at that time.  However,
the following 24 to 48 hours resulted in worsening cardiac
function requiring intra-aortic balloon pump to be replaced
and inotropic support to be resumed.  The patient over the
next week or so underwent a very slow wean of inotropic
support.  Her intra-aortic balloon pump was discontinued a
few days later.

On [**2158-4-24**], the patient went to the Electrophysiology
Laboratory for placement of a DDD permanent pacemaker due to
continued need for pacemaker support and need to suppress
atrial fibrillation which was resulting in bradycardic
rhythms.

Over the next week or so, the patient remained on low dose
Milrinone and Dobutamine.  She required continued ventilatory
support.  On [**2158-5-10**], the patient had a PICC line for
continued intravenous access placed due to finding of a
positive catheter tip culture of her central line which
revealed E. coli as well as Enterococcus which were
pansensitive.  The patient has had no subsequent positive
blood cultures and that line was discontinued.

The patient was transferred on [**2158-5-10**], to the Surgical
Intensive Care Unit/Critical Care Service due to continued
need for intensive care support. On [**2158-5-11**], the patient
underwent tracheostomy and percutaneous endoscopic
gastrostomy placement by Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**].  The patient
tolerated this procedure well and continued very slow wean
from ventilator support over the next week or so.

On [**2158-5-15**], the patient received a neurology consultation
due to generalized lethargy, decreased movement of all her
extremities and her decreased responsiveness mentally.  It
was their thought that the patient had generalized neuropathy
and myopathy and the recommendation was to obtain an EMG
which is scheduled to be done tomorrow, [**2158-5-18**].  The
patient also underwent a left upper extremity ultrasound due
to swelling of the left arm and this resulted in a negative
study for deep vein thrombosis.

Most recent laboratory values on the patient are as follows,
from [**2158-5-17**], white blood cell count 7.7, hematocrit 30.2,
platelet count 167,000.  Sodium 144, potassium 4.8, chloride
109, CO2 26, blood urea nitrogen 53, creatinine 0.8, glucose
164.  Most recent Digoxin level is from [**2158-5-16**], which
revealed a level of 1.8.  This is down from previous levels
of as high as 3.7 approximately four days prior to this.
Procainamide level on [**2158-5-16**], was 4.7 with NAPA of 17.8 at
that time.

Most recent culture data are as follows:  On [**2158-5-13**], the
patient had a stool culture sent for C. difficile which was
negative.  Central line which was discontinued on [**2158-5-9**],
was positive for E. coli as well as Enterococcus.  All
subsequent blood cultures have been negative with the
exception of yeast in her sputum and urine from [**2158-5-2**].

MEDICATIONS ON DISCHARGE:
1.  Sliding scale with regular insulin coverage q6hours as
she is continuous tube feeds. Coverage is as follows:  For
blood glucose of 120 to 140 two units subcutaneous regular
insulin, 141 to 160 four units, 161 to 180 six units, 181 to
200 eight units, 201 to 220 ten units, 221 to 240 twelve
units, 241 to 260 fourteen units, 261 to 280 sixteen units,
281 to 300 eighteen units, greater than 300 twenty units.
2.  Vioxx 25 mg per gastrostomy tube q.d.
3.  Digoxin which is on hold currently due to elevated
Digoxin level. This should be resumed at 0.125 mg q.d.
beginning on [**2158-5-18**], with levels to be followed until a
stable dose is achieved.
4.  Hydrochlorothiazide 25 mg per gastrostomy tube b.i.d.
5.  Glutamine 5 mg per gastrostomy tube b.i.d.
6.  NPH insulin 20 units subcutaneous q12hours.
7.  Zinc 200 mg per gastrostomy tube q.d.
8.  Aspirin 325 mg per gastrostomy tube q.d.
9.  Plavix 75 mg per gastrostomy tube q.d.
10. Norvasc 5 mg per gastrostomy tube q.d.
11. Lasix 40 mg per gastrostomy tube b.i.d.
12. Nystatin swish and swallow 5 ml q.i.d.
13. Procainamide 500 mg per gastrostomy tube q4hours.
14. Hydralazine 50 mg per gastrostomy tube q6hours.
15. Colace 100 mg per gastrostomy tube b.i.d.
16. Vitamin C 500 mg per gastrostomy tube b.i.d.
17. Albuterol meter dose inhaler four puffs q4hours and
p.r.n.
18. Potassium Chloride p.r.n. potassium less than 4.4.
19. Magnesium Sulfate p.r.n. magnesium less than 2.0.
20. Current tube feeding is Promote with Fiber at 50 ml per
hour. The patient is at her goal rate and tolerating it well.
21. She also receives Collagenase Ointment with dressings
applied to her sacral decubitus b.i.d. and a dry sterile
dressing to the left leg p.r.n.

The patient's operative staples were removed today and
Steri-Strips applied. Her incision is clean, dry and intake
to her sternum.

Her physical examination today is as follows:  The patient is
afebrile with stable vital signs.  She is AV paced at 90.
She previously has had atrial fibrillation which has been
suppressed with Procainamide and Digoxin.  Neurologically,
the patient is awake and oriented.  She follows commands.
She moves her right arm freely and spontaneously.  Her left
arm she does move to command.  She is not moving her legs.
The patient is lethargic at times.  Cardiovascular
examination is regular rate and rhythm, AV paced at 90 beats
per minute.  Her Digoxin is on hold currently, and the
patient has significant blood pressure discrepancy.  Her left
arm is significantly lower than her right arm due to
subclavian artery stenosis on the left.  Pulmonary
examination - Her breath sounds are coarse bilaterally.  She
is presently on pressure support ventilation which was turned
down from 12 yesterday to 10 today, 50% FIO2 which are given
her spontaneous tidal volumes of between 300 and 400
milliliters.  She has thick tan secretions although not large
amounts.  She has tolerated use of the Passimere valve
intermittently over the past two days well. Her abdomen is
obese and benign.   The patient also has a left antecubital
PICC line in place.  Her extremities are edematous.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE DIAGNOSES:
1.  Coronary artery disease, status post coronary artery
bypass graft, status post stent to the graft with perforation
and resultant emergency operation to repair the anastomosis.
2.  Respiratory failure.
3.  Diabetes mellitus.
4.  Generalized neuropathy and myopathy from prolonged
hospitalization.
5.  Atrial fibrillation with treatment resulting in
bradycardia requiring DDD permanent pacemaker placement.

FOLLOW-UP:  The patient is to follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
in the office upon discharge from rehabilitation facility.
Office telephone number is [**Telephone/Fax (1) 28544**].  Please direct any
surgery related questions to his office number.




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

Dictated By:[**Name8 (MD) 964**]
MEDQUIST36

D:  [**2158-5-17**]  20:18
T:  [**2158-5-17**]  21:01
JOB#:  [**Job Number 28545**]
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Cardiogenic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Acute respiratory failure'}


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: This is a 71 year old female
patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**], who has previously had two stents
to the right coronary artery, who was admitted to [**Hospital1 346**] initially for an outpatient cardiac
catheterization as a result of a recent positive exercise
tolerance test.

MEDICAL HISTORY: 1.  Cardiomyopathy.
2.  Congestive heart failure.
3.  Previous right coronary artery interventions, one in
[**2155**], and one in [**2156**], recent positive exercise tolerance
test on [**2158-3-24**].
4.  Hypertension.
5.  Hypercholesterolemia.
6.  Noninsulin dependent diabetes mellitus.
7.  Anxiety disorder.
8.  Obesity.
9.  Status post appendectomy.
10. Status post cholecystectomy.
11. Status post bilateral oophorectomy.

MEDICATION ON ADMISSION: 1.  Aspirin 325 mg q.d.
2.  Potassium Chloride 20 meq q.d.
3.  Bumex 1 mg q.d.
4.  Norvasc 5 mg q.d.
5.  Hydralazine 50 mg q.i.d.
6.  Imdur 30 mg q.d.
7.  Atenolol 50 mg q.d.
8.  Digoxin 0.125 mg q.d.
9.  Ativan 0.5 mg p.r.n.
10. DiaBeta 5 mg p.o. q.d.
11. Zaroxolyn 5 mg p.r.n.
12. Multivitamin one q.d.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Cardiogenic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Acute respiratory failure'}
