CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 80-year-old
male with significant coronary/vascular past medical history
(ejection fraction of 15-20%, coronary artery disease status
post coronary artery bypass grafting, peripheral vascular
disease, congestive heart failure, atrial fibrillation,
chronic renal insufficiency), admitted on [**2102-2-6**],
for an elective cardiac catheterization secondary to
increased dyspnea on exertion.

MEDICAL HISTORY: 1.  Cardiomyopathy with an ejection
fraction of 15-20%, 3+ mitral regurgitation, 2+ tricuspid
regurgitation.  2.  Status post coronary artery bypass
grafting in [**2095**] with LIMA to left anterior descending,
saphenous vein graft to obtuse marginal to ramus, and
saphenous vein graft to posterior descending artery.  3.
Peripheral vascular disease.  4.  Chronic renal
insufficiency.  5.  Congestive heart failure.  6.  Atrial
fibrillation.

MEDICATION ON ADMISSION: Coreg 3.125 b.i.d., Lanoxin 0.25
mg q.d., Zocor 10 mg q.d., Captopril 6.25 mg t.i.d., Lasix 40
p.o. q.d., Aspirin 325 q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: Father deceased of myocardial infarction at
age 48.

SOCIAL HISTORY: The patient is a former pipe smoker.  He
lives with wife.
Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other primary cardiomyopathies,Mitral valve disorders
Crnry athrscl natve vssl,CHF NOS,Iatrogen CV infarc/hmrhg,Atrial fibrillation,Urin tract infection NOS,Hyperosmolality,Protein-cal malnutr NOS,Prim cardiomyopathy NEC,Mitral valve disorder
Admission Date:  [**2102-2-6**]       Discharge Date:  [**2102-2-21**]


Service:  MEDICINE

HISTORY OF PRESENT ILLNESS:  The patient is an 80-year-old
male with significant coronary/vascular past medical history
(ejection fraction of 15-20%, coronary artery disease status
post coronary artery bypass grafting, peripheral vascular
disease, congestive heart failure, atrial fibrillation,
chronic renal insufficiency), admitted on [**2102-2-6**],
for an elective cardiac catheterization secondary to
increased dyspnea on exertion.

During the procedure, the patient was noted to have a ramus
intermedius lesion, and intervention was planned.  The
patient developed a dense right-sided hemiparesis and became
unresponsive.  He was intubated for airway protection and
transferred to the CCU.

Head CT showed no evidence of hemorrhage at that time, and
therefore it was thought likely to be a left posterior
cerebral embolus causing ischemic damage during the
procedure, and the patient was started on a Heparin drip.

MRI on [**2-7**] revealed hemorrhagic infarct/conversion
(left thalamic/occipital lobe, posterior portion, left
temporal lobe, cerebellar, and pons).  The Heparin was
stopped at this time, and a repeat CT on [**2-7**] confirmed
the bleeding.  Another repeat CT on [**2-8**] showed no
interval changes.

The patient was started on a course of Levofloxacin and
Flagyl on [**2-7**] for an increasing white count felt to be
possibly left lower lobe atelectasis versus aspiration
pneumonia.

He was transferred from the CCU to the Neurology Team on
[**2-9**] after being extubated on [**2-7**].  On [**2-12**], the patient was noted to be hypernatremic and started on
free water boluses but subsequently had desaturations to the
low 90s which improved with Lasix.

PAST MEDICAL HISTORY:  1.  Cardiomyopathy with an ejection
fraction of 15-20%, 3+ mitral regurgitation, 2+ tricuspid
regurgitation.  2.  Status post coronary artery bypass
grafting in [**2095**] with LIMA to left anterior descending,
saphenous vein graft to obtuse marginal to ramus, and
saphenous vein graft to posterior descending artery.  3.
Peripheral vascular disease.  4.  Chronic renal
insufficiency.  5.  Congestive heart failure.  6.  Atrial
fibrillation.

MEDICATIONS ON ADMISSION:  Coreg 3.125 b.i.d., Lanoxin 0.25
mg q.d., Zocor 10 mg q.d., Captopril 6.25 mg t.i.d., Lasix 40
p.o. q.d., Aspirin 325 q.d.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient is a former pipe smoker.  He
lives with wife.

FAMILY HISTORY:  Father deceased of myocardial infarction at
age 48.

PHYSICAL EXAMINATION:  Vital signs:  On transfer to the
Medical Service, temperature was 96.8??????, T-max 97.5??????, blood
pressure 90/50, ranging 90-110/50s, heart rate 51, range
60-80s, respirations 24, oxygen saturation 92% on room air.
General:  The patient was nonverbal, mildly tachypneic.
HEENT:  Slight dry mucous membranes.  Neck:  No jugular
venous distention at 45??????.  Cardiovascular:  Normal rate on
exam.  Regular rhythm.  There was a holosystolic murmur at
apex.  Positive S3.  Lungs:  Crackles at lower lung fields
bilaterally.  Abdomen:  Positive bowel sounds.  Soft and
nontender.  Extremities:  No edema.  Pneumoboots in place.
Neurological:  There was right hemiparesis.  He moved left
arm, leg, and toes spontaneously.  He had left eye lid
ptosis with left pupil dilated and minimally reactive to
light.

LABORATORY DATA:  On transfer white count was 24.6; sodium
159, BUN and creatinine 68/2.0.

Cardiac catheterization on [**2-6**]:

1.  Significant lesion in the proximal native ramus.  All
other native vessels were occluded.
2.  Patent saphenous vein graft to obtuse marginal with
occluded jump segment to RI.  Patent saphenous vein graft to
posterior descending artery and LIMA to left anterior
descending.
3.  Ramus intervention deferred secondary to development of
right-sided hemiparesis.

TTE on [**2102-2-7**], showed an ejection fraction of 15%,
with resting regional wall motion abnormalities including
interseptal akinesis, atypical akinesis, inferolateral
akinesis, and hypokinesis elsewhere, severe global right
ventricular free wall hypokinesis, moderate to severe 3+
mitral regurgitation, moderate 2+ tricuspid regurgitation.

Head CT without contrast on [**2-6**] showed no acute
intracranial pathology including no signs of intracranial
hemorrhage or infarct.

MR of head without contrast on [**2-7**] showed hemorrhagic
infarct including the left thalamus, occipital lobe,
posterior portion of the left temporal lobe, cerebellum,
upper pons, and superior aspect of the superior cerebral
peduncle.  Findings are indicative of occlusion of a portion
of the posterior cerebral artery and left superior cerebellar
artery.

MRA of the ................ showed a poorly seen left-sided
posterior cerebellar artery.  This was suggestive
atherosclerotic or embolic disease.

CT of the head without contrast on [**2-7**] showed evolving
posterior circulation infarct affecting the left occipital
lobe, temporal lobe, cerebellum, midbrain, and thalamus.

CT of the head without contrast on [**2-8**] showed stable
appearance of brain since previous study on [**2102-2-7**].

CT of the head without contrast on [**2-20**] showed
interval resolution of the previously noted hemorrhage in the
left thalamus and midbrain.  Again noted was a posterior
circulation infarct affecting the left occipital, temporal
lobes, cerebellum, midbrain, and thalamus.  There was no
evidence of hydrocephalus or mass affect.

Scrotal ultrasound on [**2-20**] showed bilateral
hydroceles.

Chest x-ray on [**2-20**] showed signs suggestive of
asymmetric congestive heart failure.

CULTURE DATA:  The patient had a urine culture on [**2-13**]
and [**2-16**] positive for 10,000-100,000 enterococcus
species which were resistant to Levofloxacin, Ampicillin, and
Vancomycin.

Urine culture sent on [**2102-2-20**], remained negative to
date.  The patient was c-diff negative times three.

The patient was with negative blood cultures throughout his
stay.  This was last sent on [**2102-2-13**].

HOSPITAL COURSE:  The patient was an 80-year-old male with a
significant history of dilated cardiomyopathy with depressed
ejection fraction (15%), coronary artery disease, chronic
renal insufficiency, admitted for elective cardiac
catheterization secondary to increased dyspnea on exertion,
who subsequently experienced a left PCA embolic stroke with
subsequent hemorrhagic transformation.

1.  Neurologic:  The patient was with events of cardiac
catheterization and initial Intensive Care Unit stay as
detailed in history of present illness.

The patient's neurologic deficits improved gradually
throughout his stay as he regained some strength and movement
of his right upper and lower extremities; however, his left
eye remained closed with a dilated pupil.

Repeat CT on [**2-20**] revealed interval resolution of
hemorrhagic infarct.  Therefore, the Stroke Team recommended
anticoagulation for a goal INR of [**2-7**], given the patient's
stroke risk in the setting of his cardiomyopathy and
depressed ejection fraction.

2.  Cardiomyopathy/congestive heart failure:  The patient had
resolved oxygen requirement throughout his stay and had an
oxygen saturation greater than 92% on room air at the time of
discharge.

He remains on Aspirin, statin, and his Digoxin was decreased
from 0.25 to 0.125 secondary to elevated levels.

The patient's ACE inhibitor and beta-blocker were held
through portions of his stay secondary to low blood
pressures, but these were added back prior to discharge and
recommend titration of dose as tolerated.

3.  Ventricular ectopy:  The patient was noted to have
frequent premature ventricular contractions and occasional
runs of nonsustained ventricular tachycardia during his stay.
The patient was found to have no significant metabolic
derangement or electrocardiogram changes suggestive of
ischemia.

Therefore, the etiology of his ectopy was felt to be related
to his structural heart disease associated with his profound
cardiomyopathy.  The patient had not been on his Carvedilol
at the time of these events, and once these were restarted,
the patient was still having occasional premature ventricular
contractions but no runs of nonsustained ventricular
tachycardia.

4.  Hypernatremia:  The patient's hypernatremia resolved
gradually with increased and free water boluses, as the
etiology was felt to be secondary to dehydration/decreased
access to free water.

Urine electrolytes were consistent with this diagnosis and
did not show any evidence for diabetes insipidus as a
potential etiology.

Sodium at the time of discharge was 141.

5.  Leukocytosis:  The patient remained afebrile and
hemodynamically stable throughout his stay, however at times
had rising white count.  Urine culture sent on [**2-13**]
revealed 10,000-100,000 enterococcus, and urinalysis revealed
white blood cells but no bacteria.

Given the rising white count in his urine results, the
patient was initiated on Ampicillin with a planned treatment
for a 14-day course (enterococcus species in urine was noted
to be resistant to Levofloxacin).

The patient remained with negative C-diff cultures and blood
cultures.  At the time of discharge, the patient's white
count had trended down and was 13.3.

6.  Acute on chronic renal failure:  At the time of transfer
to the Medicine Service, the patient's creatinine was 2.0,
and the patient was felt to be intravascularly dry, and
therefore diuresis was held.  His creatinine gradually
trended downward.  At the time of discharge, creatinine was
noted to be 0.9 with a prior baseline noted to be 1.2.

7.  Scrotal edema:  The patient was noted to have scrotal
edema which was stable throughout his stay.  Scrotal
ultrasound revealed the etiology as bilateral hydroceles.

8.  FEN:  The patient was evaluated by Speech and Swallow and
was noted to have a nonfunctional oral and pharyngeal
swallow; therefore, they recommended strict NPO with PEG tube
placement for long-term nutrition.  This was placed by
Interventional Radiology on [**2102-2-20**].

They recommend repleting potassium for less than 4 and
magnesium for less than 2, given history of coronary artery
disease.  The patient's free water boluses currently at 250
cc q.6 hours.

9.  Physical Therapy/Occupational Therapy:  The patient was
evaluated by both Physical Therapy and Occupational Therapy
and felt to be a fair candidate for a significant degree of
recovery and would therefore likely benefit from an acute
rehabilitation facility.

CONDITION ON DISCHARGE:  The patient is in stable condition,
moving all extremities, with an oxygen saturation greater
than 92% on room air.

DISCHARGE STATUS:  The patient is to be discharged to an
acute rehabilitation facility.

DISCHARGE DIAGNOSIS:
1.  Cerebrovascular accident (left PCA).
2.  Cardiomyopathy (ejection fraction of 15%).
3.  Coronary artery disease.
4.  Urinary tract infection.
5.  Hypernatremia.
6.  Congestive heart failure.
7.  Peripheral vascular disease.
8.  Anemia.
9.  Chronic renal insufficiency.

DISCHARGE MEDICATIONS:  Aspirin 325 p.o. q.d., Heparin 5000 U
subcue b.i.d., Pravastatin 20 mg p.o. q.d., Lansoprazole 30
mg p.o. q.d., Digoxin 125 mcg p.o. q.d., Carvedilol 3.125 mg
p.o. b.i.d., Captopril 12.5 mg p.o. t.i.d., Coumadin 5 mg
p.o. q.h.s., goal INR of [**2-7**], Ampicillin 1000 mg p.o. q.6
hours for 10 days to be completed on [**2102-3-2**].

FOLLOW-UP:  The patient should arrange follow-up with his
primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as appropriate.




                        DR.[**First Name (STitle) 2416**],[**First Name3 (LF) 2415**] 12-929

Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36

D:  [**2102-2-21**]  08:59
T:  [**2102-2-21**]  09:08
JOB#:  [**Job Number 15902**]
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other primary cardiomyopathies,Mitral valve disorders'}


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: The patient is an 80-year-old
male with significant coronary/vascular past medical history
(ejection fraction of 15-20%, coronary artery disease status
post coronary artery bypass grafting, peripheral vascular
disease, congestive heart failure, atrial fibrillation,
chronic renal insufficiency), admitted on [**2102-2-6**],
for an elective cardiac catheterization secondary to
increased dyspnea on exertion.

MEDICAL HISTORY: 1.  Cardiomyopathy with an ejection
fraction of 15-20%, 3+ mitral regurgitation, 2+ tricuspid
regurgitation.  2.  Status post coronary artery bypass
grafting in [**2095**] with LIMA to left anterior descending,
saphenous vein graft to obtuse marginal to ramus, and
saphenous vein graft to posterior descending artery.  3.
Peripheral vascular disease.  4.  Chronic renal
insufficiency.  5.  Congestive heart failure.  6.  Atrial
fibrillation.

MEDICATION ON ADMISSION: Coreg 3.125 b.i.d., Lanoxin 0.25
mg q.d., Zocor 10 mg q.d., Captopril 6.25 mg t.i.d., Lasix 40
p.o. q.d., Aspirin 325 q.d.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: Father deceased of myocardial infarction at
age 48.

SOCIAL HISTORY: The patient is a former pipe smoker.  He
lives with wife. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Congestive heart failure, unspecified,Iatrogenic cerebrovascular infarction or hemorrhage,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Unspecified protein-calorie malnutrition,Other primary cardiomyopathies,Mitral valve disorders'}
