CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: [**Age over 90 **] yo male with h/oCAD s/p anterior MI in [**2-15**] with a stent to
the LAD.  This was complicated by dissection of LM, which was
then stented (jailing the LCx).  Had a relook [**Date Range **] in [**5-17**] with
patent LM, LAD stentsbut extensive 3vd.  He presented today with
acute SOB and subsequently found to be in CHF.  He also had ST
depressions in V3-V5 and a TroponinT of .54.  He received
heparin, integrillin and IV lasix in the ED and taken to [**Date Range **]
lab.
[**Date Range **] showed patent LM, LAD stents, but occluded LCx.  Procedure
was complicated by inability to pass a wire into the LCx(the
stent in the LM was protruding into the aorta).  Therefore, he
was not revascularized.  Also had elevated PCWP=30 and a mixed
venous O2 of 46%. He was started on dobutamine and this
increased to 62%.  Currently, he is feeling much better.  Now
without CP, SOB, as compared to the morning, when he had PND,
SOB, and his anginal symptoms.

MEDICAL HISTORY: 1.CAD s/p anterior wall MI in [**2-15**]
2.CRI with baseline Cr of 1.7-1.9
3.PMR-on prednisone chronically
4.Hypothyroidism
5.Hypercholesterolemia
6.HTN

MEDICATION ON ADMISSION: Lipitor 10 qd
ASA 81 qd
Plavix 75 qd
Lisinopril 10 qd
Lasix 40 qd
Toprol XL 150 qd
Prednisone 10 qd
Levoxyl 75 mcg qd
Norvasc 10 qd
Omeprazole 20 qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: HR=106, BP=96/44, RR=24-28, O2 sat=100% on NRB
Gen: Mild respiratory distress, lying supine
HEENT: MMM, NCAT, No LAD
Resp: No accessory muscle use, Crackles laterally bilat.
CV:RRR, no MRG, nL S1, S2, no S3,S4
Abd:+BS, NT/ND, Soft. Abdominal Hernia present on Right.
Ext: No femoral bruits, distal pulses dopplerable bilat., 2+
pitting edema to knees bilat.
Neuro:A&O
Skin: Cool, pink

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married and lives with his wife.
[**Name (NI) **] 1 son
50 pack year smoking history, but quit 30 years ago.
True posterior wall infarction, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter
True post infarct, init,Cardiogenic shock,CHF NOS,Mitral valve disorder,Crnry athrscl natve vssl,Anemia NOS,Polymyalgia rheumatica,Hypothyroidism NOS,Renal & ureteral dis NOS
Admission Date:  [**2110-8-29**]              Discharge Date:   [**2110-9-4**]


Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization-[**2110-8-29**]

History of Present Illness:
[**Age over 90 **] yo male with h/oCAD s/p anterior MI in [**2-15**] with a stent to
the LAD.  This was complicated by dissection of LM, which was
then stented (jailing the LCx).  Had a relook [**Date Range **] in [**5-17**] with
patent LM, LAD stentsbut extensive 3vd.  He presented today with
acute SOB and subsequently found to be in CHF.  He also had ST
depressions in V3-V5 and a TroponinT of .54.  He received
heparin, integrillin and IV lasix in the ED and taken to [**Date Range **]
lab.
[**Date Range **] showed patent LM, LAD stents, but occluded LCx.  Procedure
was complicated by inability to pass a wire into the LCx(the
stent in the LM was protruding into the aorta).  Therefore, he
was not revascularized.  Also had elevated PCWP=30 and a mixed
venous O2 of 46%. He was started on dobutamine and this
increased to 62%.  Currently, he is feeling much better.  Now
without CP, SOB, as compared to the morning, when he had PND,
SOB, and his anginal symptoms.

Past Medical History:
1.CAD s/p anterior wall MI in [**2-15**]
2.CRI with baseline Cr of 1.7-1.9
3.PMR-on prednisone chronically
4.Hypothyroidism
5.Hypercholesterolemia
6.HTN


Social History:
Married and lives with his wife.
[**Name (NI) **] 1 son
50 pack year smoking history, but quit 30 years ago.

Family History:
Non-contributory

Physical Exam:
Vitals: HR=106, BP=96/44, RR=24-28, O2 sat=100% on NRB
Gen: Mild respiratory distress, lying supine
HEENT: MMM, NCAT, No LAD
Resp: No accessory muscle use, Crackles laterally bilat.
CV:RRR, no MRG, nL S1, S2, no S3,S4
Abd:+BS, NT/ND, Soft. Abdominal Hernia present on Right.
Ext: No femoral bruits, distal pulses dopplerable bilat., 2+
pitting edema to knees bilat.
Neuro:A&O
Skin: Cool, pink

Pertinent Results:
[**2110-8-29**] 12:30PM BLOOD WBC-14.9* RBC-2.97* Hgb-9.3* Hct-28.0*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.6 Plt Ct-480*
[**2110-8-29**] 10:23PM BLOOD WBC-10.8 RBC-2.58* Hgb-7.8* Hct-24.3*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.6 Plt Ct-372
[**2110-8-31**] 05:58AM BLOOD WBC-15.1*# RBC-3.40* Hgb-10.4*# Hct-30.2*
MCV-89 MCH-30.7 MCHC-34.5 RDW-15.8* Plt Ct-294
[**2110-9-1**] 05:41AM BLOOD WBC-12.4* RBC-3.47* Hgb-10.6* Hct-31.5*
MCV-91 MCH-30.6 MCHC-33.7 RDW-15.2 Plt Ct-297
[**2110-9-3**] 05:15AM BLOOD WBC-13.0* RBC-3.52* Hgb-10.6* Hct-32.0*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.6 Plt Ct-242

[**2110-8-29**] 10:23PM BLOOD Neuts-81.5* Lymphs-11.8* Monos-5.1
Eos-1.4 Baso-0.2
[**2110-9-3**] 05:15AM BLOOD Plt Ct-242
[**2110-8-29**] 12:30PM BLOOD PT-12.8 PTT-22.0 INR(PT)-1.1
[**2110-9-2**] 05:23AM BLOOD PT-12.9 PTT-45.3* INR(PT)-1.1

[**2110-8-29**] 12:30PM BLOOD Glucose-108* UreaN-44* Creat-2.1* Na-137
K-4.3 Cl-103 HCO3-19* AnGap-19
[**2110-8-31**] 05:58AM BLOOD Glucose-104 UreaN-34* Creat-1.8* Na-141
K-4.0 Cl-104 HCO3-23 AnGap-18
[**2110-9-1**] 05:41AM BLOOD Glucose-94 UreaN-35* Creat-1.6* Na-140
K-3.9 Cl-103 HCO3-27 AnGap-14
[**2110-9-3**] 05:15AM BLOOD Glucose-96 UreaN-37* Creat-1.5* Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2110-8-31**] 01:50PM BLOOD LD(LDH)-337* TotBili-0.7

[**2110-8-29**] 12:30PM BLOOD CK(CPK)-90
[**2110-8-29**] 10:23PM BLOOD CK(CPK)-135
[**2110-8-30**] 05:00AM BLOOD CK(CPK)-136
[**2110-8-30**] 12:21PM BLOOD CK(CPK)-130
[**2110-8-29**] 12:30PM BLOOD cTropnT-0.54*
[**2110-8-29**] 10:23PM BLOOD CK-MB-15* MB Indx-11.1* cTropnT-0.73*
[**2110-8-30**] 05:00AM BLOOD CK-MB-14* MB Indx-10.3*
[**2110-8-30**] 05:00AM BLOOD cTropnT-0.80*
[**2110-8-30**] 12:21PM BLOOD CK-MB-12* MB Indx-9.2*

[**2110-8-30**] 05:00AM BLOOD Calcium-7.8* Phos-4.3# Mg-1.7
[**2110-9-3**] 05:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.6

[**2110-8-31**] 01:50PM BLOOD calTIBC-209* Ferritn-458* TRF-161*
[**2110-9-1**] 05:41AM BLOOD TSH-1.1
[**2110-8-30**] 05:00AM BLOOD Cortsol-92.8*

[**2110-8-29**] 04:05PM BLOOD Type-ART pO2-61* pCO2-28* pH-7.46*
calHCO3-21 Base XS--1 Intubat-NOT INTUBA
[**2110-8-30**] 01:40AM BLOOD Type-ART O2 Flow-4 pO2-77* pCO2-33*
pH-7.47* calHCO3-25 Base XS-0 Intubat-NOT INTUBA
[**2110-8-30**] 01:42AM BLOOD Type-ART pO2-130* pCO2-34* pH-7.47*
calHCO3-25 Base XS-2
[**2110-9-1**] 05:58AM BLOOD Type-ART pO2-90 pCO2-39 pH-7.47*
calHCO3-29 Base XS-4
[**2110-8-29**] 04:05PM BLOOD Hgb-10.2* calcHCT-31 O2 Sat-91
[**2110-9-1**] 05:58AM BLOOD O2 Sat-97

[**2110-8-29**] 11:09PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-<1.005
[**2110-8-29**] 11:09PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-5.0 Leuks-TR
[**2110-8-29**] 11:09PM URINE RBC-0-2 WBC-0 Bacteri-NONE Yeast-NONE
Epi-<1
URINE CULTURE (Final [**2110-8-31**]):    NO GROWTH.

Blood and Catheter tip Cx NTD.

[**Month/Day/Year **]:
COMMENTS:
1.  Selective coronary angiography of this right dominant system

revealed severe coronary artery disease. The LMCA was extremely
difficult to engage.  It was eventually best engaged with a JL5
cattheter.  The LMCA had only mild disease. The LAD had diffuse
disease.
The previously placed LAD stent was patent.  The LCx was totally

occluded.  The RCA was not engaged.
2.  Resting hemodynamics revealed elevated right and left sided
filling
pressures with a depressed cardiac index.
3.  Failed PCI of the LCX.

FINAL DIAGNOSIS:
1.  NSTEMI.
2.  Severe coronary artery disease.
3.  Elevated filling pressures and depressed cardiac output.
4.  Failed PCI of the LCX.

Abd CT:
IMPRESSION:
1. No evidence of retroperitoneal hematoma or intraperitoneal
hematoma.
2. Infrarenal abdominal aortic aneurysm measuring 4.2 cm in
greatest dimension.
3. Bowel containing right inguinal hernia without evidence of
bowel obstruction.
4. Bilateral pleural effusions with atelectasis.

Echo: EF=35%
Conclusions:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity
size are normal. There is moderate regional left ventricular
systolic
dysfunction with focal hypokinesis of the basal half of the
inferior and
inferolateral walls and distal lateral and apical walls. The
remaining
segments contract well (suboptimal views). Right ventricular
chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary
artery systolic hypertension. There is no pericardial effusion.


Compared with the findings of the prior report (tape unavailable
for review)
of [**2-15**], the inferior and inferolateral dysfunction is new c/w
interim
ischemia/infarction. The severity of mitral regurgitation has
slightly
increased.


Brief Hospital Course:
This [**Age over 90 **] yo male with a CAD history came from the [**Age over 90 **] lab on
dobutamine due to CHF in the setting of his acute MI.  He was
not able to be revascularized.

1.CAD: He was put on ASA, Plavix, and a statin, but not heparin,
as his vessel is totally occluded.  A B-blocker and ACE-I were
initially held due to hypotension.  His enzymes were followed
until they began to trend down.  NTG was used as needed for
chest pain.  His BP began to improve, and his dobutamine was
weaned off.  An ACE-I was gradually added as his BP would
tolerate, and then a B-blocker was added as he recovered
further.  On D/C, he was on stable doses of both with good
tolerance of his BP and heart rate.  He remained CP free
throughout the hospitalization.  He had daily ECGs which showed
no new ischemia.  He was sent home with NTG to use for anginal
pain.
2.Pump:  He was initially in CHF with high filling pressures and
MR [**First Name (Titles) **] [**Last Name (Titles) **].  Likely result of acute MI.  He was initially on
dobutamine post-[**Last Name (Titles) **].  This was weaned, but his BP was kept at
levels high enough to ensure renal perfusion and adequate CO.
He was also given Lasix as needed for gentle diuresis as his BP
would tolerate.  This improved his pulmonary symptoms.  In
addition, an ACE-I was added as soon as he could tolerate it for
afterload reduction.  This was not done immediately, as he
remained on the hypotensive side early in his admission. He was
requiring O2 due to maintain adequate oxygenation.  By D/C, he
was maintaining adequate O2 saturations on room air.  He had an
echo which showed an EF of 35%  His LE edema, pulmonary edema,
and JVD all gradually resolved as he recovered in the hospital.
He had an arterial line placed to help monitor his blood
pressure, as his peripheral BP was not always a true
measurement.  He was sent home with a prescription for Lasix 20
mg with instructions to weigh himself daily and take 1 tablet if
his weight increases 2 lbs or more in one day.
3.Rhythm: He remained in NSR, but did have a good number of
PACs.  These were all asymptomatic and not treated.
4.Pulmonary: As above, he initially required O2 due to pulm
edema from CHF.  As he was diuresed with doses of lasix, and his
heart recovered some function, all symptoms improved.  He was
free of oxygen by discharge.
5.CRI:Post-[**Last Name (Titles) **], he was intravascularly dry and had received a
dye load.  His Cr increased to 2.1 from his baseline of 1.6-1.7.
 It quickly returned to his baseline the next day, and remained
there until D/C.
6.PMR: He is on chronic prednisone at home.  Adrenal
insufficiency was considered due to hypotension, as were stress
dose steroids.  It was decided that he was adequately covered
with his home doses, and these were continued.  No issues.
7.Hypothyroidism: Continued levothyroxine at home doses withiut
issue.  TSH was nL on this admission.
8.He was stabilized and transferred to the floor after several
days in the ICU.  He did well there, eating and drinking well.
He was seen by PT and they recommended he have home PT on D/C.
He was sent home to his wife and son for further recovery.  He
was not interested in rehab at this time.  We did set up a VNA
and home PT for him.


Medications on Admission:
Lipitor 10 qd
ASA 81 qd
Plavix 75 qd
Lisinopril 10 qd
Lasix 40 qd
Toprol XL 150 qd
Prednisone 10 qd
Levoxyl 75 mcg qd
Norvasc 10 qd
Omeprazole 20 qd

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
8. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
9. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Take 1 tab every 5 minutes for chest pain.  Maximum 3 tabs in 15
minutes.  If pain not resolved, go to the ED.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO as directed:
Please weigh yourself daily.  If weight increases by 2 lbs or
more from one day to the next, then take 1 tab of Lasix that
day.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Posterior ST elevation MI
Chronic renal insufficiency
Polymyalgia rheumatica
Hypothyroidism


Discharge Condition:
Pt was stable.  Ambulating with assistance off of oxygen.No
chest pain or SOB with exertion.

Discharge Instructions:
Please call your doctor or return to the hospital if you have
new chest pain or shortness of breath at home.

STOP your Norvasc and Lasix.
Your dose of Lipitor was increased from 10 mg/day to 40 mg/day.
Your dose of Toprol XL was decreased from 150 mg/day to 50
mg/day.

Weigh yourself every day.  If your weight increases by 2 lbs or
more from one day to the next day, then take 20 mg of Lasix that
day.

Followup Instructions:
Please call Dr [**Last Name (STitle) **] to arrange a cardiology follow-up
appointment in 3 weeks to 1 month.

Please call your PCP to arrange [**Name Initial (PRE) **] follow-up in 1 week.

Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4023**] Date/Time:[**2111-2-19**] 3:30


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]



Name:  [**Known lastname 14791**],[**Known firstname 14792**]                    Unit No:   [**Numeric Identifier 14793**]

Admission Date:  [**2110-8-29**]              Discharge Date:   [**2110-9-4**]

Date of Birth:  [**2018-8-2**]             Sex:   M

Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Cardiac catheterization [**2110-8-29**]


Brief Hospital Course:
Note for PCP: [**Name10 (NameIs) **] [**Known lastname **]' echocardiogram demonstrated valvular
disease significant enough to be classified as moderate risk for
endocarditis.  He will need to have antibiotic prophylaxis for
any dental work.

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 328**] VNA

Discharge Diagnosis:
Posterior ST elevation MI
Chronic renal insufficiency
Polymyalgia rheumatica
Hypothyroidism


Discharge Condition:
Pt was stable.  Ambulating with assistance off of oxygen.No
chest pain or SOB with exertion.

Discharge Instructions:
Please call your doctor or return to the hospital if you have
new chest pain or shortness of breath at home.

STOP your Norvasc and Lasix.
Your dose of Lipitor was increased from 10 mg/day to 40 mg/day.
Your dose of Toprol XL was decreased from 150 mg/day to 50
mg/day.

Weigh yourself every day.  If your weight increases by 2 lbs or
more from one day to the next day, then take 20 mg of Lasix that
day.

Followup Instructions:
Please call Dr [**Last Name (STitle) 690**] to arrange a cardiology follow-up
appointment in 3 weeks to 1 month.

Please call your PCP to arrange [**Name Initial (PRE) **] follow-up in 1 week.

Provider: [**First Name8 (NamePattern2) 77**] [**First Name8 (NamePattern2) 2448**] [**Name8 (MD) **], M.D. Where: [**Hospital6 189**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 14794**] Date/Time:[**2111-2-19**] 3:30


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 950**] MD, [**MD Number(3) 951**]

Completed by:[**2110-9-4**]
{'True posterior wall infarction, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter'}


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: Shortness of breath

PRESENT ILLNESS: [**Age over 90 **] yo male with h/oCAD s/p anterior MI in [**2-15**] with a stent to
the LAD.  This was complicated by dissection of LM, which was
then stented (jailing the LCx).  Had a relook [**Date Range **] in [**5-17**] with
patent LM, LAD stentsbut extensive 3vd.  He presented today with
acute SOB and subsequently found to be in CHF.  He also had ST
depressions in V3-V5 and a TroponinT of .54.  He received
heparin, integrillin and IV lasix in the ED and taken to [**Date Range **]
lab.
[**Date Range **] showed patent LM, LAD stents, but occluded LCx.  Procedure
was complicated by inability to pass a wire into the LCx(the
stent in the LM was protruding into the aorta).  Therefore, he
was not revascularized.  Also had elevated PCWP=30 and a mixed
venous O2 of 46%. He was started on dobutamine and this
increased to 62%.  Currently, he is feeling much better.  Now
without CP, SOB, as compared to the morning, when he had PND,
SOB, and his anginal symptoms.

MEDICAL HISTORY: 1.CAD s/p anterior wall MI in [**2-15**]
2.CRI with baseline Cr of 1.7-1.9
3.PMR-on prednisone chronically
4.Hypothyroidism
5.Hypercholesterolemia
6.HTN

MEDICATION ON ADMISSION: Lipitor 10 qd
ASA 81 qd
Plavix 75 qd
Lisinopril 10 qd
Lasix 40 qd
Toprol XL 150 qd
Prednisone 10 qd
Levoxyl 75 mcg qd
Norvasc 10 qd
Omeprazole 20 qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: HR=106, BP=96/44, RR=24-28, O2 sat=100% on NRB
Gen: Mild respiratory distress, lying supine
HEENT: MMM, NCAT, No LAD
Resp: No accessory muscle use, Crackles laterally bilat.
CV:RRR, no MRG, nL S1, S2, no S3,S4
Abd:+BS, NT/ND, Soft. Abdominal Hernia present on Right.
Ext: No femoral bruits, distal pulses dopplerable bilat., 2+
pitting edema to knees bilat.
Neuro:A&O
Skin: Cool, pink

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married and lives with his wife.
[**Name (NI) **] 1 son
50 pack year smoking history, but quit 30 years ago. 

### Response:
{'True posterior wall infarction, initial episode of care,Cardiogenic shock,Congestive heart failure, unspecified,Mitral valve disorders,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Polymyalgia rheumatica,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter'}
