CHIEF COMPLAINT: chest pain

PRESENT ILLNESS: Mr. [**Name13 (STitle) 106855**] is a 68-year-old man who was discharged to rehab
after a coronary artery bypass grafting on [**2146-11-11**], he now
presents with chest pain and a supertherapeutic INR.

MEDICAL HISTORY: - h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia

MEDICATION ON ADMISSION: clonazepam .5mg [**Hospital1 **], sildenafil 10 mg
[**Hospital1 **],fluticasone-salmeterol 250-50 mcg [**Hospital1 **]  digoxin 125 mcg
DAILY,nicotine 7 mg/24 hr Patch, Calcium 600 + D(3) 600-400
mg-unit daily, simvastatin 80 mg daily, multivitamin DAILY,
folic
acid 1 mg DAILY, famotidine 20 mg DAILY, aspirin 81 mg  DAILY,
pantoprazole 40 mg daily, midodrine 10 mg TID, tamsulosin 0.4 mg
hs,oxycodone 5mg prn, amiodarone 200 mg daily
,ipratropium-albuterol 2Puffs Q6H, furosemide 40 mg Tablet
DAILY,
potassium chloride 20 mEq DAILY , Coumadin 2.5 mg as directed
for
AFIB/PE

ALLERGIES: Seroquel / Fentanyl / Flagyl

PHYSICAL EXAM: Pulse: 70 Resp: 18 O2 sat: 98%
B/P  Right: 126/78
Height: 6'0"  Weight: 84.8 kg

FAMILY HISTORY: father and mother both died of CAD, dad died after age >50

SOCIAL HISTORY: Mr. [**Name13 (STitle) 106855**] is unemployed and live alone.  He smoked 1.5 packs
per day for about 50 years, but quit 3 months ago. He has a
history of heavy alcohol use, but quit 9 months ago.
Hemopericardium,Acute and subacute bacterial endocarditis,Rupture of chordae tendineae,Other postoperative infection,Intestinal infection due to Clostridium difficile,Acute osteomyelitis, other specified sites,Obstructive chronic bronchitis with (acute) exacerbation,Chronic pulmonary embolism,Atrial fibrillation,Alcoholic cirrhosis of liver,Abnormal coagulation profile,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of anticoagulants,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Fitting and adjustment of cardiac pacemaker
Hemopericardium,Ac/subac bact endocard,Chordae tendinae rupture,Other postop infection,Int inf clstrdium dfcile,Ac osteomyelitis NEC,Obs chr bronc w(ac) exac,Chr pulmonary embolism,Atrial fibrillation,Alcohol cirrhosis liver,Abnrml coagultion prfile,Hypertension NOS,Hyperlipidemia NEC/NOS,Pseudomonas infect NOS,Long-term use anticoagul,Abn react-anastom/graft,Carrier NEC,Ftng cardiac pacemaker
Admission Date:  [**2146-12-13**]              Discharge Date:   [**2147-1-6**]

Date of Birth:  [**2078-1-10**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Seroquel / Fentanyl / Flagyl

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain

Major Surgical or Invasive Procedure:
Incision and drainage of sternal wound [**2146-12-19**]


History of Present Illness:
Mr. [**Name13 (STitle) 106855**] is a 68-year-old man who was discharged to rehab
after a coronary artery bypass grafting on [**2146-11-11**], he now
presents with chest pain and a supertherapeutic INR.

Past Medical History:
- h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia


Social History:
Mr. [**Name13 (STitle) 106855**] is unemployed and live alone.  He smoked 1.5 packs
per day for about 50 years, but quit 3 months ago. He has a
history of heavy alcohol use, but quit 9 months ago.


Family History:
father and mother both died of CAD, dad died after age >50

Physical Exam:
Pulse: 70 Resp: 18 O2 sat: 98%
B/P  Right: 126/78
Height: 6'0"  Weight: 84.8 kg

General: Pleasant, no acute distress laying in bed
Skin: Dry [x] * sternal incision w redness at upper and lower
[**1-23**]- outlined, sensitive to touch
 mid line abdomen, left groin, midline neck surgical scars
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur no
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Cool Edema none Varicosities: None [x]
Neuro: Alert and oriented x3 residual right upper nad lower
extremity weakness
Pulses:
Femoral      Right: +1  Left: +1
DP           Right:  +1  Left: +1
PT           [**Name (NI) 167**]:  +1  Left: +1
Radial       Right: +1  Left: +1

Carotid Bruit        Right: bruit   Left: no bruit


Pertinent Results:
[**2146-12-14**] Echo:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic root is mildly dilated at
the sinus level. The descending thoracic aorta is mildly
dilated. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is a small to moderate sized
circumferential pericardial effusion without echocardiographic
signs of tamponade.

IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity sizes with preserved global systolic function. Right
ventricular cavity enlargement with free wall hypokinesis.
Compared with the report of the prior study (images unavailable
for review) of [**2146-11-8**], a small-moderate circumferential
pericardial effusion is now present. The severity of tricuspid
regurgitation and the estimated pulmonary artery systolic
pressure are now reduced.



[**2147-1-6**] 09:35AM BLOOD WBC-14.8* RBC-2.79* Hgb-7.8* Hct-23.8*
MCV-85 MCH-28.0 MCHC-32.8 RDW-16.8* Plt Ct-335
[**2147-1-6**] 09:35AM BLOOD PT-19.2* PTT-37.2* INR(PT)-1.8*
[**2147-1-6**] 09:35AM BLOOD Glucose-119* UreaN-25* Creat-0.6 Na-140
K-4.0 Cl-98 HCO3-35* AnGap-11

Brief Hospital Course:
Mr. [**Known lastname 63108**] was admitted and given Vitamin K for an INR 6.7.  He
remained on bed-rest until INR came below 5.  His echo revealed
a small, 1.2 cm circumferential pericardial effusion without
evidence of tamponade. Sternal erythema was noted and IV
vancomycin and oral cipro were started.  Additionally, he
developed small, fluctuant collections of the sternal incision.
These were incised and drained to reveal blood and serous fluid.
 There was no pus or evidence of infection.  He remained on
antibiotics and wound was the packed. His INR continued to drift
down.  The erythema continued to progress on antibiotics and the
sternum became unstable.  The patient was brought to the
operating room on [**2146-12-20**] for sternal exploration and
debridement with a vacuum dressing placement.  He underwent a
subsequent debridement on [**12-23**] with the plastic surgery
service.  On [**12-29**] he had a third debridement with a vacuum
dressing placement.  On [**1-2**] he had a fourth debridement with
pec and omental flap.  Please see the operative notes for
details.  He was seen in consultation by the ID service for an
OR culture that grew pseudomonas and for c.diff (PCR positive)
diarrhea.  He was placed on oral Vancomycin and ceftazapine.  He
was started on TPN due to poor oral intake.  He was started on
wellbutrin to help with smoking cessation and any depression
that may be inhibiting his poor oral intake.  Coumadin was
started for atrial fibrillation and history of pulmonary
embolism, but due to his extreme sensitivity toward coumadin,
only low doses were used and INR was checked daily. His
permanaent pacemaker was interrogated secondary to what appeared
to be oversensing, but the electrophysiology service felt that
it was pacing appropriately to APCs.  He complained of a painful
abdomen but was given maalox with resolution of his symptoms. By
post-operative day 25 he was ready for discharge to rehab.  All
follow-up appointments were advised.

Medications on Admission:
clonazepam .5mg [**Hospital1 **], sildenafil 10 mg
[**Hospital1 **],fluticasone-salmeterol 250-50 mcg [**Hospital1 **]  digoxin 125 mcg
DAILY,nicotine 7 mg/24 hr Patch, Calcium 600 + D(3) 600-400
mg-unit daily, simvastatin 80 mg daily, multivitamin DAILY,
folic
acid 1 mg DAILY, famotidine 20 mg DAILY, aspirin 81 mg  DAILY,
pantoprazole 40 mg daily, midodrine 10 mg TID, tamsulosin 0.4 mg
hs,oxycodone 5mg prn, amiodarone 200 mg daily
,ipratropium-albuterol 2Puffs Q6H, furosemide 40 mg Tablet
DAILY,
potassium chloride 20 mEq DAILY , Coumadin 2.5 mg as directed
for
AFIB/PE



Discharge Medications:
1. Outpatient Lab Work
laboratory monitoring required - cbc diff bun cr lfts
frequency - weekly

Creat
bun
T bili
Alt
Ast
Alk ph
wbc
Hct/Hgb
Dose
Drug peak
Drug trough

All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]

2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
4. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): plan for 14 days treatment, unless otherwise directed
by the infectious disease service .
Disp:*120 Capsule(s)* Refills:*2*
8. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
9. ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours): plan for 6-8 weeks total
treatment after final debridement unless otherwise directed by
the infectious disease service.
Disp:*2 Recon Soln(s)* Refills:*2*
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
13. warfarin 1 mg Tablet Sig: 0.5 Tablet PO ONCE (Once) for 1
doses: total of 0.5mg daily for 2 weeks, INR goal [**2-23**] for
afib/PE (patient very sensitive to coumadin).
Disp:*30 Tablet(s)* Refills:*2*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days: then taper to home dose of 40mg daily.
Disp:*20 Tablet(s)* Refills:*2*
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for gas pain.
Disp:*30 ML(s)* Refills:*0*
16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
[**1-22**] puff Inhalation twice a day.
Disp:*qs * Refills:*2*
17. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
18. Wellbutrin SR 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day: 150mg daily for 3 days,
then increase to [**Hospital1 **] for smoking cessation .
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
19. ipratropium bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*qs puffs* Refills:*0*
20. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs * Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]

Discharge Diagnosis:
supratherapeutic INR
PMH:
coronary artery disease s/p cabg
Hypertension
Peripheral vascular disease
Atrial fibrillation
Chronic obstructive pulmonary disease
Upper GI bleed [**8-30**] d/t gastritis esophagitis
ischemic esophagus
pulmonary embolism
liver disease
Pulmonary hypertension on viagra
Anemia
Epitaxis
Right side paralysis at age 1
Bacteremia - pseudomonas [**8-/2146**]
Past Surgical History
Emergent Cricothyroidotomy with tracheostomy [**8-/2146**] d/t
epiglottic bleeding
Right leg fracture repair at age 6
Aortobifem
Permanent pacemaker
AAA repair [**2143**]


Discharge Condition:
Alert and oriented x3 nonfocal
Deconditioned
Incisional pain managed with Oxycodone
Incisions:
Sternal - clean, dry, intact
Leg Left - healing well, no erythema or drainage. 1+ lower
extremity edema


Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions.
Maintain tegaderm dressing placed in OR by plastic surgery
service.  It will be removed during their follow-up appointment.
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart

No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]

Follow INR daily until therapeutic INR 2.5 for afib and histroy
of PE in [**2146-8-21**].

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2146-12-28**]
1:45, will need an [**Month/Day/Year 461**] before the appointment.
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-1-11**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2147-1-24**] 10:40
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2147-1-10**] 10:50
Please see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (plastic surgery) in 2 weeks. ([**Telephone/Fax (1) 14596**]
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) 84032**] [**Telephone/Fax (1) 28612**] in [**4-25**] weeks
Schedule a follow up appointment with your hematologist in 2
weeks.

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

INR goal [**2-23**] for a-fib with history of PE
First draw on [**2147-1-7**]
Please arrange for INR follow-up at discharge



Completed by:[**2147-1-6**]

Name:  [**Known lastname 17447**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 17448**]

Admission Date:  [**2146-12-13**]              Discharge Date:   [**2147-1-6**]

Date of Birth:  [**2078-1-10**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Seroquel / Fentanyl / Flagyl

Attending:[**First Name3 (LF) 135**]
Addendum:
Mr. [**Name13 (STitle) 17449**] was discharged to [**Hospital **] [**Hospital 4534**] rehab.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2215**] - [**Location (un) 95**] - [**Location (un) 4534**]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]

Completed by:[**2147-1-6**]
{'Hemopericardium,Acute and subacute bacterial endocarditis,Rupture of chordae tendineae,Other postoperative infection,Intestinal infection due to Clostridium difficile,Acute osteomyelitis, other specified sites,Obstructive chronic bronchitis with (acute) exacerbation,Chronic pulmonary embolism,Atrial fibrillation,Alcoholic cirrhosis of liver,Abnormal coagulation profile,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of anticoagulants,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Fitting and adjustment of cardiac pacemaker'}


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: chest pain

PRESENT ILLNESS: Mr. [**Name13 (STitle) 106855**] is a 68-year-old man who was discharged to rehab
after a coronary artery bypass grafting on [**2146-11-11**], he now
presents with chest pain and a supertherapeutic INR.

MEDICAL HISTORY: - h/o atrial Fibrillation
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober now)
- Anemia: h/o maroon stools; colonoscopy in [**2146**] with
hemorrhoids, colon polyps, adenoma
- h/o epistaxis
- history of AAA that was repaired in 07
- h/o PE ~2-3 months ago per pt. Notes from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] mention
PE and imaging from today mentions stable PE. However, no
records at [**Hospital1 18**] mention PE.
- Wedge fractures - Noted in lumbar region on CT scan
- prolonged hospitalization at [**Hospital1 18**] in [**8-30**] for epiglottitis
requiring cric/trach, with hospital course complicated by GI
bleeding and pseudonomas bacteremia

MEDICATION ON ADMISSION: clonazepam .5mg [**Hospital1 **], sildenafil 10 mg
[**Hospital1 **],fluticasone-salmeterol 250-50 mcg [**Hospital1 **]  digoxin 125 mcg
DAILY,nicotine 7 mg/24 hr Patch, Calcium 600 + D(3) 600-400
mg-unit daily, simvastatin 80 mg daily, multivitamin DAILY,
folic
acid 1 mg DAILY, famotidine 20 mg DAILY, aspirin 81 mg  DAILY,
pantoprazole 40 mg daily, midodrine 10 mg TID, tamsulosin 0.4 mg
hs,oxycodone 5mg prn, amiodarone 200 mg daily
,ipratropium-albuterol 2Puffs Q6H, furosemide 40 mg Tablet
DAILY,
potassium chloride 20 mEq DAILY , Coumadin 2.5 mg as directed
for
AFIB/PE

ALLERGIES: Seroquel / Fentanyl / Flagyl

PHYSICAL EXAM: Pulse: 70 Resp: 18 O2 sat: 98%
B/P  Right: 126/78
Height: 6'0"  Weight: 84.8 kg

FAMILY HISTORY: father and mother both died of CAD, dad died after age >50

SOCIAL HISTORY: Mr. [**Name13 (STitle) 106855**] is unemployed and live alone.  He smoked 1.5 packs
per day for about 50 years, but quit 3 months ago. He has a
history of heavy alcohol use, but quit 9 months ago. 

### Response:
{'Hemopericardium,Acute and subacute bacterial endocarditis,Rupture of chordae tendineae,Other postoperative infection,Intestinal infection due to Clostridium difficile,Acute osteomyelitis, other specified sites,Obstructive chronic bronchitis with (acute) exacerbation,Chronic pulmonary embolism,Atrial fibrillation,Alcoholic cirrhosis of liver,Abnormal coagulation profile,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Long-term (current) use of anticoagulants,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Carrier or suspected carrier of other specified infectious organism,Fitting and adjustment of cardiac pacemaker'}
