CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 77 year old man
with a history of atrial fibrillation and aortic valve
replacement, who presented to his primary care physician's
office on the day of admission with one to two weeks of
progressive dyspnea.  It has evolved to the point where the
patient is only able to walk two to three steps before he
must sit down.  Over the last week, the patient has also been
taking sublingual nitroglycerin with these episodes three to
four times per day.  This has not given him any relief.

MEDICAL HISTORY: 1.  Status post aortic valve replacement secondary to
rheumatic heart disease in [**2184**].
2.  Atrial fibrillation.
3.  Type 2 diabetes mellitus.
4.  Status post gunshot wound to left leg.
5.  History of left lower extremity cellulitis.
6.  History of gastrointestinal bleeding attributed to
gastritis, requiring over 20 units of blood transfusions
earlier this year.
7.  Chronic renal failure.
8.  History of colonic adenoma.
9.  History of diverticulosis.

MEDICATION ON ADMISSION: Protonix 40 mg p.o.q.d., Coumadin
10 mg p.o.q.d., Glucotrol XL 5 mg p.o.b.i.d., digoxin 0.125
mg p.o.q.d., Lasix 40 mg p.o.q.d., Prozac 20 mg p.o.q.d.,
Zestril 20 mg p.o.q.d., Zocor 20 mg p.o.q.d., iron 325 mg
p.o.b.i.d.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with his wife of 50 years.
He has a remote history of tobacco and alcohol use.
Angiodysplasia of stomach and duodenum with hemorrhage,Congestive heart failure, unspecified,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Intestinal infection due to Clostridium difficile,Drug-induced delirium
Angio stm/dudn w hmrhg,CHF NOS,Atrial fibrillation,Other pulmonary insuff,Pneumonia, organism NOS,Hyperosmolality,Int inf clstrdium dfcile,Drug-induced delirium
Admission Date:  [**2199-1-4**]       Discharge Date:  [**2199-1-28**]

Date of Birth:   [**2121-8-10**]       Sex:  M

Service:  Medicine

HISTORY OF PRESENT ILLNESS:  The patient is a 77 year old man
with a history of atrial fibrillation and aortic valve
replacement, who presented to his primary care physician's
office on the day of admission with one to two weeks of
progressive dyspnea.  It has evolved to the point where the
patient is only able to walk two to three steps before he
must sit down.  Over the last week, the patient has also been
taking sublingual nitroglycerin with these episodes three to
four times per day.  This has not given him any relief.

The patient denies chest pain, nausea, vomiting or
diaphoresis with these events.  He sleeps on three pillows.
He describes difficulty sleeping over the last several weeks,
but denies paroxysmal nocturnal dyspnea.  He does not note
increased swelling of his lower extremities.  He describes an
occasional productive cough with yellow sputum but denies
fevers.  He has had a decrease in his appetite recently.

The patient has a history of gastrointestinal bleed.  He
notes a small amount of blood on the toilet paper over the
past weeks.  He denies bright red blood per rectum as well as
hematemesis.

PAST MEDICAL HISTORY:
1.  Status post aortic valve replacement secondary to
rheumatic heart disease in [**2184**].
2.  Atrial fibrillation.
3.  Type 2 diabetes mellitus.
4.  Status post gunshot wound to left leg.
5.  History of left lower extremity cellulitis.
6.  History of gastrointestinal bleeding attributed to
gastritis, requiring over 20 units of blood transfusions
earlier this year.
7.  Chronic renal failure.
8.  History of colonic adenoma.
9.  History of diverticulosis.

MEDICATIONS ON ADMISSION:  Protonix 40 mg p.o.q.d., Coumadin
10 mg p.o.q.d., Glucotrol XL 5 mg p.o.b.i.d., digoxin 0.125
mg p.o.q.d., Lasix 40 mg p.o.q.d., Prozac 20 mg p.o.q.d.,
Zestril 20 mg p.o.q.d., Zocor 20 mg p.o.q.d., iron 325 mg
p.o.b.i.d.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient lives with his wife of 50 years.
He has a remote history of tobacco and alcohol use.

PHYSICAL EXAMINATION:  On physical examination on admission,
the patient had a temperature of 98.9, blood pressure 126/59,
heart rate 81, respiratory rate 25 and oxygen saturation 96%
on two liters.  General:  Patient in no acute distress, alert
and oriented times three, speaking in complete sentences.
Head, eyes, ears, nose and throat:  Pupils equal, round, and
reactive to light and accommodation, positive left cataract,
extraocular movements intact, anicteric sclerae, oropharynx
clear.  Neck:  No lymphadenopathy, jugular venous pressure at
9 cm, supple.  Lungs:  Bilateral crackles two-thirds of the
way on the left, one-half of the way on the right, moving air
in all segments.  Cardiovascular:  Mechanical click,
irregularly irregular rhythm, II/VI systolic ejection murmur
at right upper sternal border.  Abdomen:  Soft, nontender,
nondistended, positive bowel sounds.  Rectal:  Normal tone,
no masses, heme positive brown stool, no hemorrhoids, no
fissures.  Genitourinary:  Scrotal edema, reportedly
unchanged per patient.  Extremities:  No cyanosis, clubbing
or edema in upper extremities, hyperemia of venous stasis in
lower extremities with some edema of right lower extremity,
2+ pitting edema mid-calf and below in left lower extremity,
no ulcers.  Neurologic examination:  Alert and oriented times
three, cranial nerves II through XII intact, motor and
sensation grossly intact.

LABORATORY DATA:  Admission white blood cell count was 7.9,
hematocrit 28.6, platelet count 208,000, INR 1.8, partial
thromboplastin time 32.4, sodium 139, potassium 5.1, chloride
106, bicarbonate 22, BUN 66, creatinine 2.2, glucose 110, ALT
12, AST 25, alkaline phosphatase 214, amylase 100, lipase 71,
total bilirubin 0.5, CK/MB 3 and troponin-I less than 0.3.
Chest x-ray:  No evidence of congestive heart failure, no
infiltrate.  Electrocardiogram:  Atrial fibrillation,
unchanged from prior tracing except for inverted T waves in
V4 and V5.  Right lower extremity Doppler:  Preliminary read
negative.

HOSPITAL COURSE:  1.  Gastrointestinal:  Of note, the patient
has a history of presenting with shortness of breath when he
has had anemia secondary to gastrointestinal bleeding.  His
stool was guaiac positive on admission.  The patient was
transfused one unit of blood, with an appropriate increase in
his hematocrit to 32.1 and his heparin was continued for
aortic valve replacement related anticoagulation.

The patient was transfused another unit of blood on [**2199-1-5**] for a hematocrit of 28.9, again with an appropriate
increase to 32.8.  At this time, he continued to have guaiac
negative stools and no melena.  When the patient had another
drop in his hematocrit to 29.1 on [**2199-1-8**], the
gastroenterology service was contact[**Name (NI) **] regarding possible
endoscopy.  At this time, they declined endoscopy because the
patient has had multiple upper endoscopies and an colonoscopy
earlier this year, which revealed gastritis.  On [**2199-1-8**], the patient's Protonix was increased to 40 mg every 12
hours.

On the afternoon of [**2199-1-9**], the patient noted
melena.  On [**2199-1-10**], his hematocrit decreased to
27.5.  On [**2199-1-12**], the gastroenterology service was
consulted for occult gastrointestinal bleed evaluation.  The
gastroenterology service opted to do an endoscopy to evaluate
the status of his gastritis and possible arteriovenous
malformation.

On [**2199-1-14**], the patient's hematocrit decreased to a
level of 24.7.  The patient was transferred to the Medical
Intensive Care Unit for more intensive monitoring in the
setting of his gastrointestinal bleed.  The patient received
an upper endoscopy on [**2199-1-14**], which revealed a
single nonbleeding arteriovenous malformation in the pylorus
of the stomach, which was electrocauterized, as well as a
single small arteriovenous malformation with stigmata of
recent bleeding in the jejunum, which was also
electrocauterized.

The patient continued to have a low hematocrit, with blood
transfusion requirements and a tagged red blood cell scan was
performed, which was negative for evidence of active
bleeding.  The patient also underwent a colonoscopy on
[**2198-1-17**], which revealed two nonbleeding polyps in the
ascending and descending colon as well as multiple
nonbleeding, not diverticula, in all portions of the colon.

After this, the patient maintained his hematocrit in response
to the red blood cell transfusions and he was called out of
the Medical Intensive Care Unit on [**2199-1-22**].  From
this time until the time of dictation ([**2199-1-27**]), the
patient had a stable hematocrit in the range of 32 to 34.  He
has had guaiac negative stools and no evidence of
gastrointestinal bleeding.  He has continued on a twice a day
proton pump inhibitor.

2.  Cardiovascular:  Both heart failure and cardiac ischemia
were felt to be in the differential diagnosis for the
patient's shortness of breath on presentation.  On [**2199-1-7**], the patient underwent a pharmacological stress
test, which was negative for evidence of ischemia.  He
received an echocardiogram on [**2199-1-8**], which
revealed a left ventricular ejection fraction of about 40%,
depressed right ventricular function with evidence of right
greater than left heart failure.  The patient was continued
on his Captopril, Isordil, Zocor, digoxin and Lasix.

While in the Medical Intensive Care Unit, the patient became
hypotensive, requiring fluid boluses and, briefly, a
dobutamine drip.  In response to the fluids he received, the
patient developed evidence of heart failure on physical
examination and on chest x-ray.  He was successfully diuresed
and, at the time of dictation, had much improved oxygen
saturation and ease of breathing.

After the patient's stay in the MICU, the patient was noted
to have a substantial amount of ventricular ectopy.  He had
one 18 beat run of nonsustained ventricular tachycardia.  The
electrophysiology service was consulted and they recommended
that he be continued on rate control for atrial fibrillation
(metoprolol) without a recommendation for an ICD or
amiodarone.

The patient was anticoagulated for his prosthetic aortic
valve except when he had evidence of active gastrointestinal
bleeding.  After his endoscopy and electrocauterization
procedure, the patient was placed on heparin again and
eventually on Coumadin until his INR became therapeutic at a
left between 2.5 and 3.5.

3.  Pulmonary:  At the time of the patient's admission to the
Intensive Care Unit, the patient was in respiratory distress
and was intubated without complications.  On [**2199-1-18**],
the patient was placed on pressure support ventilation.  He
continued to improve with diuresis.  He was extubated on
[**2199-1-21**] and has not had significant respiratory
difficulties on minimal oxygen from nasal cannula since then.

4.  Infectious disease:  While in the Intensive Care Unit,
the patient had a chest x-ray which was suggestive of
possible ventilator associated pneumonia.  He was also noted
to have substantial erythema of the left lower extremity,
possibly consistent with cellulitis.  The patient was placed
on Unasyn to complete a 14 day course.

On [**2199-1-25**], the patient was noted to have a large
quantity of loose stool.  His stool test for Clostridium
difficile toxin was positive and the patient was started on a
14 day course of Flagyl.  The patient did not grow any
organisms from his blood or urine cultures throughout
admission.

5.  Renal:  The patient has chronic renal failure with a
baseline creatinine in the vicinity of 2.  His creatinine
increased to a level of around 3 at the time of his admission
to the MICU.  At the time of discharge, the patient had
improvement back to his baseline level.

6.  Musculoskeletal:  On the evening of [**2199-1-10**],
the patient was noted to have severe pain in the left
popliteal region.  A lower extremity Doppler ultrasound was
performed, which was negative for deep vein thrombosis but
positive for a ruptured [**Hospital Ward Name 4675**] cyst.  The patient was
treated with analgesic medications for the pain from this
cyst.  An orthopedic consult did not recommend any
intervention and did not feel that the patient had any
evidence of compartment syndrome.

7.  Neurologic:  The patient was noted to have delirium after
his stay in the Medical Intensive Care Unit.  Sedating
medications were avoided and the patient's mental status
gradually improved to the point where he is currently
oriented to his location, the month and year, and his reason
for admission to the hospital.

The above is a dictation of the [**Hospital 228**] hospital course
through [**2199-1-27**].  Please refer to a discharge
addendum for discharge medications and additional discharge
information.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D.  [**MD Number(1) 1212**]

Dictated By:[**Last Name (NamePattern1) 5596**]
MEDQUIST36

D:  [**2199-1-27**]  04:44
T:  [**2199-1-27**]  18:26
JOB#:  [**Job Number **]


Name:  [**Known lastname 18261**], [**Known firstname **] J.                     Unit No:  [**Numeric Identifier 18262**]

Admission Date:  [**2199-1-4**]       Discharge Date: [**2199-1-29**]

Date of Birth:   [**2121-8-10**]       Sex:  M

Service:

ADDENDUM:  Hospital course addendum;

1.  INFECTIOUS DISEASE:  The patient received a full 2-week
course of Unasyn at 1.5 g intravenously b.i.d. for left lower
lobe ventilation associated pneumonia.

2.  CARDIOVASCULAR SYSTEM:  Although the patient was well
diuresed, he still had lower leg edema due to congestive
heart failure, so his Lasix was increased from 40 mg to 80 mg
p.o. b.i.d. on [**2199-1-29**].  His creatinine should be
monitored while on the Lasix.  His atrial fibrillation was
well rate controlled.

3.  PSYCHIATRY:  The patient's delirium resolved once Haldol
was discontinued and Risperidol started at 1 mg p.o. q.h.s.
For his depression, he was restarted on Prozac 20 mg p.o.
q.d.

DISCHARGE DIAGNOSES:
 1.  Gastrointestinal bleed secondary to arteriovenous
malformation; status post electrocauterization.
 2.  Atrial fibrillation.
 3.  Aortic valve replacement.
 4.  Congestive heart failure.
 5.  Type 2 diabetes mellitus.
 6.  Chronic renal failure with a baseline creatinine of 2.
 7.  Status post pneumonia.
 8.  Clostridium difficile infection.
 9.  Delirium secondary to Haldol.
10.  Depression.

MEDICATIONS ON DISCHARGE:
 1.  Metoprolol 12.5 mg p.o. b.i.d.
 2.  Digoxin 0.25 mg p.o. q.d.
 3.  Lisinopril 20 mg p.o. q.d.
 4.  Lasix 80 mg p.o. b.i.d.
 5.  Glipizide-XL 5 mg p.o. q.d.
 6.  Flagyl 500 mg p.o. t.i.d. (end on [**2199-2-8**]).
 7.  Coumadin 5 mg p.o. q.h.s.
 8.  Protonix 40 mg p.o. b.i.d.
 9.  Atrovent 2 puffs inhaled q.i.d.
10.  Albuterol 1 to 2 puffs inhaled q.4-6h. as needed.
11.  Risperidol 1 mg p.o. q.h.s.
12.  Zyprexa 5 mg p.o. q.h.s. as needed.
13.  Prozac 20 mg p.o. q.d.






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D.  [**MD Number(1) 225**]

Dictated By:[**Last Name (NamePattern1) 4387**]
MEDQUIST36

D:  [**2199-1-29**]  15:09
T:  [**2199-1-29**]  15:24
JOB#:  [**Job Number **]
{'Angiodysplasia of stomach and duodenum with hemorrhage,Congestive heart failure, unspecified,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Intestinal infection due to Clostridium difficile,Drug-induced delirium'}


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 a 77 year old man
with a history of atrial fibrillation and aortic valve
replacement, who presented to his primary care physician's
office on the day of admission with one to two weeks of
progressive dyspnea.  It has evolved to the point where the
patient is only able to walk two to three steps before he
must sit down.  Over the last week, the patient has also been
taking sublingual nitroglycerin with these episodes three to
four times per day.  This has not given him any relief.

MEDICAL HISTORY: 1.  Status post aortic valve replacement secondary to
rheumatic heart disease in [**2184**].
2.  Atrial fibrillation.
3.  Type 2 diabetes mellitus.
4.  Status post gunshot wound to left leg.
5.  History of left lower extremity cellulitis.
6.  History of gastrointestinal bleeding attributed to
gastritis, requiring over 20 units of blood transfusions
earlier this year.
7.  Chronic renal failure.
8.  History of colonic adenoma.
9.  History of diverticulosis.

MEDICATION ON ADMISSION: Protonix 40 mg p.o.q.d., Coumadin
10 mg p.o.q.d., Glucotrol XL 5 mg p.o.b.i.d., digoxin 0.125
mg p.o.q.d., Lasix 40 mg p.o.q.d., Prozac 20 mg p.o.q.d.,
Zestril 20 mg p.o.q.d., Zocor 20 mg p.o.q.d., iron 325 mg
p.o.b.i.d.

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives with his wife of 50 years.
He has a remote history of tobacco and alcohol use. 

### Response:
{'Angiodysplasia of stomach and duodenum with hemorrhage,Congestive heart failure, unspecified,Atrial fibrillation,Other pulmonary insufficiency, not elsewhere classified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Intestinal infection due to Clostridium difficile,Drug-induced delirium'}
